Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

evidence that the newborn is becoming chilled.

a good time to initiate breast-feeding.

the period of decreased responsiveness preceding sleep.

A sign that the infant is being overstimulated.

Answer and Explanation

The Correct Answer is B

A. Evidence that the newborn is becoming chilled would typically include signs such as cool skin, mottling, or acrocyanosis ,not active behaviors like head movement and eye contact.
B. A good time to initiate breast-feeding is correct. The described behaviors ,eye contact, head movement, and tongue thrusting, are characteristic of the first period of reactivity, which occurs within the first 30 minutes after birth. During this time, the newborn is alert, responsive, and exhibits strong rooting and sucking reflexes, making it an ideal window to begin breastfeeding.
C. The period of decreased responsiveness preceding sleep typically occurs after the first period of reactivity and is marked by reduced activity and interest in feeding, not alert behaviors.
D. A sign that the infant is being overstimulated would usually involve signs like gaze aversion, hiccupping, or flailing ,not purposeful movements or eye contact.

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Correct Answer is D

Explanation

A. "I need to call my doctor if my temperature increases." This is an appropriate and accurate statement. An elevated temperature could be a sign of infection, which is a risk for women with preterm prelabor rupture of membranes (PPROM). The woman should contact her healthcare provider if her temperature rises, as infection can lead to complications.

B. "I can shower, but I shouldn't take a tub bath." This is also correct. After PPROM, the woman is typically allowed to shower to maintain personal hygiene, but taking a tub bath can increase the risk of infection by allowing bacteria to enter the vagina.

C. "I need to keep a close eye on how active my baby is each day." This is a correct and helpful statement. Monitoring fetal movement is important for assessing the baby's well-being. Decreased fetal movement could indicate a potential problem, and the woman should contact her provider if she notices reduced activity.

D. "It's okay for my husband and me to have sexual intercourse." This statement indicates a need for additional teaching. Sexual intercourse is typically not recommended after PPROM because it could increase the risk of infection, especially if the membranes are ruptured. The woman should avoid sexual activity until advised otherwise by her healthcare provider.

A. reduces lochia B. promotes uterine involution C. improves pelvic floor tone D. alleviates perineal pain

Correct Answer is C

Explanation

A. Lochia is the normal postpartum vaginal discharge of blood and tissue, and its duration or volume is not affected by Kegel exercises.
B. Uterine involution ,the shrinking of the uterus to its pre-pregnancy size ,is a natural physiological process and is not influenced by Kegel exercises.
C. Kegel exercises specifically target the pelvic floor muscles, which may be weakened during pregnancy and childbirth. These exercises help strengthen the muscles, support pelvic organs, and prevent issues such as urinary incontinence.
D. While improved muscle tone may eventually support healing, these exercises are not a direct method for pain relief.

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Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching?

Correct Answer is D

Explanation

A nurse is teaching a postpartum client how to do muscle-clenching (Kegel) exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

Correct Answer is C

Explanation

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

The new mother asks the nurse about the presence of a small blood-tinged area on her daughter's diaper. Which response by the nurse would be most accurate?

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?