1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

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?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

A nurse is caring for a newborn 1 hr following birth.

Medical History 1000:

39- week gestation

Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min

Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?