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A nurse is caring for a newborn 1 hr following birth.

Medical History 1000:

39- week gestation

Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min

Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.

Hemoglobin

Hematocrit

Heart rate

Serum glucose

White blood cells

Respiratory assessment

Answer and Explanation

Correct Answer : A,B,C,D,F

A, B Monitoring the newborn's hemoglobin and hematocrit levels are important due to the risk of anemia.

C. Monitoring the newborn's heart rate post-birth is crucial for assessing cardiac function and detecting any abnormalities.

F. Positive pressure ventilation was administered to the newborn for 1 minute after birth, indicating a need for respiratory support. The nurse should closely assess the newborn's respiratory status.

D. There may be concerns about the newborn's blood glucose levels, especially if there were any periods of hypoxia or stress during labor and delivery.

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Correct Answer is C

Explanation

This action is important as it helps to prevent hypothermia, which newborns are particularly susceptible to. However, while drying the infant is essential, it should not be the very first action taken immediately after birth.

Stimulating the infant to cry can help establish normal respiratory function and is important for transitioning to extrauterine life. However, it may not be the first action if the infant is not breathing or appears to need immediate airway clearance.

This is a critical first step, especially if the newborn is not breathing adequately. Clearing the airway (using suction if necessary) is vital to ensure that the infant can breathe properly and transition well after birth. If there are any signs of airway obstruction or if the infant is not crying, this action takes precedence.

While cutting the umbilical cord is a standard procedure, it is typically performed after ensuring the infant is stable. Current guidelines suggest delaying cord clamping for a short period unless there are complications that require immediate action.

A. "I will rest in a recliner until my incision is healed." B. "I will call my provider if I have discharge from my incision." C. "I will resume taking my prenatal vitamins." D. "I should not have unrelieved pain in my abdomen." E. "I am likely to have a fever during the first week I am home

Correct Answer is ["B","D"]

Explanation

B. This statement indicates the client understands the importance of monitoring the incision site for any signs of infection, such as discharge, and knows to seek medical attention if these signs occur.
D. This statement indicates the client understands that while some discomfort is normal after a cesarean birth, unrelieved or severe pain could be a sign of complications and should be addressed promptly.
A. Resting in a recliner may not provide adequate support or promote proper healing of the incision site.
C. While continuing prenatal vitamins may be beneficial for overall health, it is not directly related to the cesarean birth recovery process.
E. A fever during the first week at home is not a typical occurrence and may indicate an infection, which should be evaluated by a healthcare provider. Therefore, it is not accurate to expect a fever during this time.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

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 is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. 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?