A nurse is caring for a newborn.

The newborn was delivered via cesarean birth approximately 1 hr ago.

The Apgar Scores are 8 and 9. Vitamin K was administered in the left vastus lateralis.

The weight is 4337 grams (9 lb 9 oz), length 52 cm (20.5 in), and gestational age assessment of 39 weeks. The newborn is large for gestational age and noted to be jittery and have decreased muscle tone. Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn’s progress.

Check the newborn’s capillary blood glucose level.

Place the newborn under a radiant warmer.

Monitor the newborn’s temperature.

Monitor the newborn’s color and frequency of bowel movements.

Answer and Explanation

The Correct Answer is A,B,C

Choice A rationale

Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.

Choice B rationale

Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.

Choice C rationale

Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.

Choice D rationale

Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.

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Correct Answer is A

Explanation

Choice A rationale

Physiologic jaundice is a common condition in newborns, usually appearing between the second and fourth day of life. It is caused by an increase in bilirubin, a substance produced by the breakdown of red blood cells.

Choice B rationale

Maternal/newborn blood group incompatibility can cause jaundice, but it typically appears within the first 24 hours of life.

Choice C rationale

Maternal cocaine abuse can lead to various complications in the newborn, but it does not directly cause jaundice.

Choice D rationale

Absence of vitamin K does not cause jaundice. Vitamin K is given to newborns to prevent bleeding disorders.

A. Document the findings and continue to monitor the client B. Encourage the client to empty her bladder C. Notify the client’s provider D. Increase the frequency of fundal massage

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Documenting the findings and continuing to monitor the client is appropriate because the nurse has already observed that the fundus is midline and firm, which indicates good uterine tone. The presence of lochia rubra and small clots is expected in the immediate postpartum period.

Choice B rationale: Encouraging the client to empty her bladder can help maintain uterine tone, but in this scenario, the fundus is already firm and midline, so this is not the priority action.

Choice C rationale: Notifying the client's provider is unnecessary at this time because the findings are within normal postpartum expectations and the uterus is firm.

Choice D rationale: Increasing the frequency of fundal massage is not needed because the uterus is already firm and midline, indicating that it is contracting properly.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an antepartum clinic is caring for a client who is pregnant. Select the assessment findings the nurse should report to the provider.

A nurse is caring for a client who has just delivered a newborn. The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which of the following explanations should the nurse provide?

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?