A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?

A newborn who has subconjunctival hemorrhage of the left eye

A newborn who has overlapping suture lines

A newborn who has nasal flaring

A newborn who has rust stained urine

Answer and Explanation

The Correct Answer is C

A. Subconjunctival hemorrhage is common after vaginal delivery and usually harmless.
B. Overlapping suture lines are normal in newborns due to molding during birth.
C. Nasal flaring is a sign of respiratory distress and requires immediate assessment.
D. Rust-stained urine can be due to urate crystals and is usually benign in newborns.

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Correct Answer is B

Explanation

A. Nausea is a common and generally mild side effect of oral contraceptives and does not typically require immediate medical attention.
B. Persistent headaches may indicate an increased risk of stroke or hypertension, especially in clients with other risk factors. This could be a sign of a serious adverse effect and should be reported to the provider immediately.
C. Breast tenderness is a common and usually benign side effect of hormonal contraceptives.
D. Abdominal bloating may occur but is not typically dangerous or an urgent concern.

A. A client who reports changing their perineal pad every 4 hr. B. A client who has a urine output of 750 mL in 6 hr. C. A client who has 1+ deep tendon reflexes while receiving IV magnesium sulfate. D. A client who reports abdominal cramping pain during breastfeeding.

Correct Answer is A

Explanation

A. Changing a perineal pad only every 4 hours may indicate excessive bleeding or hemorrhage, which requires immediate assessment.
B. A urine output of 750 mL in 6 hours is within normal limits (about 125 mL/hr).
C. 1+ deep tendon reflexes indicate decreased reflexes, which is expected during magnesium sulfate therapy and generally not an immediate concern.
D. Abdominal cramping during breastfeeding is common due to uterine contractions and is usually not urgent.

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A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about potential adverse effects of oral contraceptives. For which of the following adverse effects should the nurse instruct the client to notify the provider immediately?

Correct Answer is B

Explanation

A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

Correct Answer is A

Explanation

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