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 B

Explanation

A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.

B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.

C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.

D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.

A. Cries vigorously when stimulated B. A positive Babinski reflex C. Heart rate of 220 beats/minute D. Flexion of all four extremities

Correct Answer is A

Explanation

A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.

B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.

C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.

D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.

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Naxlex Comprehensive Predictor Exams

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?

Correct Answer is B

Explanation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

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During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

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