A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

The newborn's cord stump is still attached after 1 week.

The newborn sleeps 16 hr a day.

The newborn has fewer than four wet diapers in 24 hr

The newborn has loose stools.

Answer and Explanation

The Correct Answer is C

A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.

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Correct Answer is ["C","D"]

Explanation

A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.

B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.

C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.

D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.

E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.

F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.

A. High-pitched crying B. Tachypneic respirations C. Body tremors D. Extreme lethargy E. Decreased reflexes

Correct Answer is ["A","B","C"]

Explanation

A. High-pitched, excessive crying is a common sign of neonatal abstinence syndrome (NAS).
B. Tachypnea (rapid breathing) is a typical respiratory symptom of NAS.
C. Body tremors and jitteriness are classic signs of withdrawal in newborns.
D. Newborns with NAS typically exhibit hyperactivity, not extreme lethargy.
E. Reflexes are usually increased (hyperactive), not decreased, in NAS.

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A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D"]

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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