A nurse is caring for a newborn who is 72 hr old.

Physical Examination

1100:

Neonatal Abstinence Scoring System (NAS)

Excessive high-pitched cry-2 Sleeps <2 hr 2
Hyperactive Moro reflex=2 Moderate-severe tremors disturbed=2 Increased muscle tone=2
Fever <37.2 to 38.2° C (99 to 100.8° F)=1

Excessive sucking=1 Frequent sneezing=1

Frequent yawning-1 Loose stools=2 Poor feeding=2
Respiratory rate > 60/min=1 Mottling-1
NAS score 20

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a newborn 8 hours of age

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1°C (97°F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosal Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted. Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A nurse is caring for a postpartum client.

Click to highlight the client statements that indicate an understanding of the discharge teaching.

"Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

"I should make sure that my baby feeds 8 to 12 times per day."

"I should cover my sore nipples with plastic-lined breast pads after every feeding."

"My baby's stools should turn to a yellow color within the next day or two.

I can increase my milk supply by drinking more water.

I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores