Exhibit 1. Exhibit 2. Exhibit 3. Nurses' notes:. Decreased activity level over the last 12 hr. Abdominal distention. Three bloody stools over the last 4 hr. Superficial rash on the abdominal wall. Light palpation of the abdomen leads to fist clenching, thrashing, and crying. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.

Insert an orogastric decompression tube with low wall suction.

Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.

Administer nitric oxide inhalation therapy to the newborn.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.

Choice D rationale:

Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Hct (hematocrit) of 34% is a normal finding during pregnancy. Normal ranges vary during pregnancy, but generally, a hematocrit between 33% to 45% is considered normal during the second trimester.

Choice B rationale:

BUN (blood urea nitrogen) of 25 mg/dL should be reported to the provider. BUN measures kidney function, and during pregnancy, values above 20 mg/dL may indicate possible impaired kidney function, which requires further evaluation.

Choice C rationale:

Platelets of 170,000/mm³ are within the normal range during pregnancy. The normal platelet count during pregnancy is typically between 150,000 to 400,000/mm³.

Choice D rationale:

HbA1c (glycated hemoglobin) of 6% is a good indicator of blood sugar control and is within the target range for a pregnant woman with diabetes. The target HbA1c level for pregnant women with diabetes is usually around 6% or lower.

A. Provide the client with a cool sitz bath. B. Administer methylergonovine 0.2 mg IM. C. Apply a moist, warm compress to the perineum. D. Apply povidone-iodine to the client's perineum after she voids.

Correct Answer is A

Explanation

The correct answer is choice a. Provide the client with a cool sitz bath.

Choice A rationale:

A cool sitz bath can help reduce swelling and provide pain relief for a client with a fourth-degree laceration of the perineum. Cooling the area can also help minimize inflammation and promote healing.

Choice B rationale:

Methylergonovine is typically used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of perineal lacerations.

Choice C rationale:

Applying a moist, warm compress to the perineum is not recommended immediately postpartum for a fourth-degree laceration, as it can increase swelling and discomfort. Cool treatments are preferred initially.

Choice D rationale:

Applying povidone-iodine to the perineum is not a standard practice for managing perineal lacerations. It can cause irritation and is not necessary for wound care in this context.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take?

A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse identify as the priority to report to the provider?

A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications?

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?