A nurse is caring for a newborn who is 4 hours old in the maternity unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities, all of which are signs of low blood sugar. The newborn's large birth weight (4,366 g) further increases the risk of hypoglycemia. Immediate feeding is crucial to increase blood sugar levels, and phototherapy can help manage any potential jaundice, which is often associated with hypoglycemia.

Feeding the newborn is essential to provide glucose and stabilize blood sugar levels. Monitoring phototherapy ensures effective treatment of jaundice, which often coexists with hypoglycemia in newborns.

Assessing skin integrity is necessary to prevent complications from jaundice and ensure proper phototherapy response. Monitoring bilirubin levels helps track jaundice severity and the effectiveness of treatment.

Kernicterus, a severe form of jaundice, is less likely because the newborn's symptoms primarily indicate hypoglycemia. Neonatal Abstinence Syndrome, due to maternal drug use, typically involves different symptoms such as irritability, excessive crying, and poor feeding. Congenital Syphilis is ruled out as the mother was treated and tests for syphilis are negative.

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Correct Answer is B

Explanation

Choice A rationale

Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.

Choice B rationale

Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.

Choice C rationale

White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.

Choice D rationale

Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.

A. I should breastfeed my baby at least six times per day. B. I should keep my baby on a strict breastfeeding schedule. C. I should feed my baby for 30 minutes during each feeding. D. I should hold my baby just below the level of my breast.

Correct Answer is C

Explanation

Choice A rationale

Breastfeeding at least six times per day is too infrequent for a newborn. Newborns typically need to feed more frequently, approximately 8-12 times in 24 hours, to establish a good milk supply and ensure adequate nutrition.

Choice B rationale

Keeping a baby on a strict breastfeeding schedule is not recommended. Feeding should be on demand, based on the baby's hunger cues, to promote effective breastfeeding and milk production.

Choice C rationale

Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.

Choice D rationale

Holding the baby just below the level of the breast is incorrect. The baby should be held at breast level to facilitate proper latch and comfortable feeding for both mother and baby. .

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is collecting data from a client who is at 26 weeks of gestation.Which of the following findings reported by the client should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching about breastfeeding with a client.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assisting with the care of a 30-year-old female client who is scheduled to receive a dose of dinoprostone in the maternal newborn unit. Exhibits For which of the following findings should the nurse anticipate a provider's prescription to withhold the dinoprostone? Select all that apply.

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