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A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR: 96.6° F (35.9° C), 158, 62, jittery, pink body with bluish hands and feet, crying.Which of the following nursing actions is of highest importance?

Swaddle the baby to provide warmth.

Assess the glucose level of the baby.

Take the baby to the mother for feeding.

Administer the routine neonatal medications.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.

Choice B rationale

Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.

Choice C rationale

Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.

Choice D rationale

Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Choice A rationale

Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.

Choice B rationale

Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.

Choice C rationale

Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.

Choice D rationale

Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.

Choice E rationale

Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.

A. Massage her fundus until firm and ensure IV access. B. Administer pain medication and prepare for possible surgical intervention. C. Reassess her vital signs and monitor for further changes. D. Immediately contact the attending physician for emergency intervention.

Correct Answer is A

Explanation

Choice A rationale

Massaging the fundus can help contract the uterus and reduce bleeding. Ensuring IV access is crucial for administering medications rapidly. Methylergonovine (Methergine) and oxytocin help stimulate uterine contractions and reduce postpartum hemorrhage, which can be life-threatening.

Choice B rationale

Administering pain medication might be necessary, but it doesn't address the immediate issue of uterine atony and hemorrhage. Surgical intervention is a last resort and should be prepared for only if medical management fails.

Choice C rationale

Reassessing vital signs and monitoring is important, but it doesn't provide an immediate solution to the bleeding and uterine atony. Immediate action to contract the uterus is crucial.

Choice D rationale

Contacting the attending physician is important, but immediate intervention to stop the bleeding and address uterine atony is critical to prevent further complications.

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Naxlex Comprehensive Predictor Exams

When assisting with a vacuum-assisted vaginal delivery, the nurse is aware that adherence to which guidelines for the vacuum device will minimize the nurse's liability in vacuum-assisted vaginal births? Select all that apply.

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

Explanation

Correct Answer is A

Explanation

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?

The nurse is assisting the primary care provider (PCP) with the third stage of a vaginal delivery.The patient is multiparous, experienced a precipitous birth, and has a history of hypertension.Which medical prescription does the nurse anticipate for this patient?

A patient with pregestational diabetes mellitus delivers a neonate who is diagnosed with macrosomia.The nurse is aware that the neonate is at risk for additional long-term conditions related to maternal diabetes mellitus.Which long-term effects may occur? Select all that apply.

A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness.The nurse knows these are signs and symptoms of which obstetrical emergency?

A client is on magnesium sulfate for pre-eclampsia with severe features.The nurse must notify the attending physician regarding which of the following findings?

A preterm labor client at 30 weeks' gestation reported rupture of membranes 4 hours ago.This was confirmed on examination.The nurse prepares to administer IM dexamethasone.When the client asks why she is receiving the drug, the nurse replies: