An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Assign a practical nurse (PN) to reassess the client's vital signs.

Obtain a STAT hemoglobin and hematocrit

Notify the healthcare provider of the assessment findings

Determine if the client received anesthesia during delivery

Answer and Explanation

The Correct Answer is C

A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.

B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.

C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.

D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.

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Correct Answer is A

Explanation

A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.

B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.

C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.

D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.

A. Place client in a negative pressure room B. Implement droplet precautions C. Encourage the mother to bottle-feed D. Give antiviral medication intravenously E. Use standard precautions

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

Explanation

A. Place client in a negative pressure room:HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.

B. Implement droplet precautions:HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.

C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.

D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).

E. Use standard precautions:Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.

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Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is A

Explanation

A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

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

Explanation

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

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