A nurse is conducting an initial assessment of a newborn delivered with a nuchal cord. What clinical findings should the nurse anticipate?

Facial petechiae

Erythema toxicum

Periauricular papillomas

Telangiectatic nevi

Answer and Explanation

The Correct Answer is A

Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that can occur when a newborn has a nuchal cord, or the umbilical cord wrapped around the neck. This is due to the pressure exerted on the baby’s face and neck during delivery.
Choice B rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by red skin. However, it is not specifically associated with a nuchal cord.
Choice C rationale
Periauricular papillomas are small skin tags or pits seen near the ear. They are a common minor anomaly seen in newborns, but they are not associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by small, light pink patches, usually on the back of the neck. However, they are not associated with a nuchal cord.

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Correct Answer is D

Explanation

Choice A rationale
A temperature of 37.4°C (99.3°F) is within the normal range and does not indicate endometritis.
Choice B rationale
Scant lochia is not typically associated with endometritis. In fact, women with endometritis may experience heavy lochia or foul-smelling lochia.
Choice C rationale
A WBC count of 9,000/mm is within the normal range and does not indicate endometritis.
Choice D rationale

Uterine tenderness is a common symptom of endometritis. Other symptoms can include fever, malaise, and foul-smelling lochia.

A. Provide oxygen to the client via a nonrebreather face mask. B. Administer oxytocin to the client. C. Empty the client’s bladder. D. Massage the client’s fundus.

Correct Answer is D

Explanation

Choice A rationale
Providing oxygen to the client via a nonrebreather face mask is important if the client shows signs of hypoxia or shock due to blood loss. However, it is not the first action the nurse should take.
Choice B rationale
Administering oxytocin to the client can help contract the uterus and control bleeding, but it is not the first action the nurse should take.
Choice C rationale

Emptying the client’s bladder can help the uterus contract more effectively, but it is not the first action the nurse should take.
Choice D rationale
The first action the nurse should take when noting excessive vaginal bleeding is to massage the client’s fundus. A boggy uterus can lead to excessive bleeding, and massaging the fundus helps the uterus contract and can control the bleeding.

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A nurse is conducting an initial assessment of a newborn delivered with a nuchal cord. What clinical findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hours postpartum and has endometritis. What findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What action should the nurse take first?

Correct Answer is D

Explanation

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