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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Correct Answer is C

Explanation

The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:

a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.

A. Fetal bradycardia. B. Decreased ability to bear down. C. Maternal hypertension. D. Uterine hyperstimulation.

Correct Answer is B

Explanation

The correct answer is choiceB. Decreased ability to bear down.

Choice A rationale:

Fetal bradycardia is not a common adverse effect of a pudendal nerve block.This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.

Choice B rationale:

Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.

Choice C rationale:

Maternal hypertension is not associated with pudendal nerve blocks.This block is localized and does not generally affect systemic blood pressure.

Choice D rationale:

Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks.This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.

Correct Answer is B

Explanation

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

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 assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse?

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?

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery?