The RN has received a hand-off report.
Which client does the RN need to see first?

The client having trouble breastfeeding.

The client who had a postpartum hemorrhage 3 hours ago.

The client complaining of pain of 5 out of 10 and requesting pain medication.

The client with a history of pre-eclampsia and now has a BP of 130/90.

Answer and Explanation

The Correct Answer is B

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Correct Answer is D

Explanation

Choice A rationale

Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.

Choice B rationale

Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.

Choice C rationale

Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.

Choice D rationale

Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .

A. Initiate phototherapy. B. Administer intravenous dextrose. C. Perform a lumbar puncture. D. Encourage frequent breastfeeding or formula feeding. E. Administer naloxone.

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

Explanation

Choice A rationale: Initiating phototherapy is essential for treating neonatal jaundice. Phototherapy helps to break down bilirubin in the skin, reducing serum bilirubin levels and preventing complications such as kernicterus. It is a common and effective treatment for elevated bilirubin levels in newborns.

Choice B rationale: Administering intravenous dextrose addresses the newborn's low blood glucose level. Hypoglycemia in newborns can lead to severe neurological complications if not treated promptly. Dextrose administration helps stabilize blood glucose levels, improving the newborn's overall condition.

Choice C rationale: Performing a lumbar puncture is not indicated in this scenario. The newborn's symptoms and diagnostic results do not suggest a need for this procedure. Lumbar punctures are typically performed to diagnose conditions such as meningitis, which is not evident here.

Choice D rationale: Encouraging frequent breastfeeding or formula feeding helps in reducing bilirubin levels and maintaining blood glucose levels. Adequate feeding promotes regular bowel movements, aiding in the excretion of bilirubin, and ensures the newborn receives necessary nutrients to stabilize blood glucose levels.

Choice E rationale: Administering naloxone is used for opioid withdrawal, which is not relevant in this case. The newborn's symptoms do not indicate opioid exposure, so this intervention is unnecessary.

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The RN has received a hand-off report.Which client does the RN need to see first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a newborn in the neonatal unit. The newborn was delivered via cesarean birth approximately 1 hour ago. Below are the exhibits. Exhibits Which of the following interventions should the nurse prioritize for this newborn? Select all that apply.

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

Explanation

A newborn is reported to have breastfed very well during the first successful feeding after birth.The baby is now 4 hours old and has not had a second feeding.The nurse would:

The nurse calculates the 1-minute Apgar score of a neonate with the following characteristics to be: Heart rate 60; weak cry, partial flexion of extremities; weak suck; gray color.

A nurse is assisting a client with breastfeeding.Which of the following reflexes will promote the newborn to latch?

A nurse is caring for a client who is considering several methods of contraception.Which method should the nurse identify as being most reliable?

A nurse is caring for a newborn who is 56 hours old.Vital signs at 0700: Heart rate 168/min, Respiratory rate 70/min, Temperature 36.1°C (97.0°F), Oxygen saturation 97%. The nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?

A 35-year-old patient is getting her labs drawn at the six weeks post-partum check-up. Upon assessment, the nurse notes swelling in the patient's left leg, and the patient reports pain and tenderness in the calf.The nurse knows which lab results are responsible?

A home health nurse is teaching a client who is breastfeeding about managing engorgement.Which statement indicates understanding of the teaching?

A newly admitted postpartum client who delivered vaginally has saturated 6 perineal pads with bright red blood and many small clots during a one-hour period.The nurse suspects a post-partum hemorrhage.The nurse knows that a risk factor for post-partum hemorrhage is:

The RN has received a hand-off report.
Which client does the RN need to see first?