The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Perform a vaginal exam.

Take vital signs.

Palpate the bladder.

Examine the amniotic fluid.

Dipstick urine for protein and ketones.

Answer and Explanation

Correct Answer : A,B

Choice A rationale

Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.

Choice B rationale

Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.

Choice C rationale

Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.

Choice D rationale

Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.

Choice E rationale

Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.

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Correct Answer is B

Explanation

Choice B rationale

Providing multidisciplinary resources and ongoing support is crucial for newborns exposed to methadone. This approach helps in managing withdrawal symptoms and ensures the child receives comprehensive care.

Choice A rationale

Keeping the newborn in the nursery may be beneficial initially but does not address the long-term needs of the child and the family.

Choice C rationale

Administering methadone to the newborn is not typically done unless specifically indicated by the healthcare provider.

Choice D rationale

Calling social services for foster care placement may be necessary in some cases, but providing support and resources to the mother and child is the primary intervention.

A. Bulb syringe use. B. Newborn screening tests. C. Techniques to breastfeed. D. Circumcision care.

Correct Answer is C

Explanation

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

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The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn with suspected neonatal abstinence syndrome.The mother is currently taking methadone and is in a treatment program.Which intervention should the nurse implement prior to discharge?

Correct Answer is B

Explanation

A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

Correct Answer is C

Explanation

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