A nurse is caring for a mother who delivered vaginally 2 hr ago.
Axillary temperature 36.6° C (98.0° F). Heart rate 110/min.
Respiratory rate 24/min.
Oxygen saturation 94%. Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at vagina.
Correct Answer : A,B,C,D
Choice A rationale
Respiratory assessment is crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.
Choice B rationale
Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.
Choice C rationale
A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.
Choice D rationale
A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While burping is important after feeding to prevent discomfort and regurgitation, it does not directly indicate overall health or hydration status.
Choice B rationale
Frequent loose yellow stools are typical in breastfed infants and indicate proper digestion and nutrition, but do not address overall hydration status directly.
Choice C rationale
Steady weight gain indicates good nutrition and overall health in the infant, reflecting adequate feeding and hydration.
Choice D rationale
Sleeping through the night is not an expectation for newborns, as they typically need frequent feeding due to small stomach capacity and rapid growth needs.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Apgar score assesses the newborn's health at 1 and 5 minutes post-delivery. A score of 8 at 1 minute and 10 at 5 minutes indicates good initial adaptation to extrauterine life.
Choice B rationale
Suctioning the mouth with a bulb syringe helps clear the airway of any meconium, which can be crucial to prevent respiratory complications.
Choice C rationale
Absence of visible meconium in the airway reduces the risk of meconium aspiration syndrome, a serious condition affecting the newborn's respiratory system.
Choice D rationale
Antibiotics are not routinely started after birth for all infants; they are used if there is a high risk or evidence of infection.
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