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 ["A","D"]

Explanation

A. Dark red vaginal bleeding is often seen in placental abruption. The blood from an abruption is typically dark red (indicating that it is older blood) and may be mixed with amniotic fluid, making it more challenging to assess. However, the bleeding can sometimes be concealed, especially in complete abruption or retroplacental hemorrhage, where blood accumulates behind the placenta.

B. Absence of pain is incorrect. In fact, placental abruption is typically associated with abdominal pain, which can be severe and often comes on suddenly. Pain occurs due to the detachment of the placenta from the uterine wall and subsequent irritation or bleeding into the uterine cavity.

C. Insidious onset is incorrect. Placental abruption usually has a sudden or acute onset of symptoms, such as vaginal bleeding and abdominal pain. An insidious onset would be more suggestive of other conditions, such as placenta previa.

D. Absent fetal heart tones is a critical finding. Placental abruption can cause fetal distress or fetal death, especially if the abruption is severe. Absent fetal heart tones are a sign of fetal compromise or death resulting from the disruption of placental blood flow.

A. Wrap the newborn in a blanket. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Dry the newborn thoroughly.

Correct Answer is D

Explanation

A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.

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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 suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

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

Explanation

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Correct Answer is D

Explanation

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

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

Which action by the nurse is most effective to prevent sore nipples in a breastfeeding client?

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The nurse knows that the occurrence of shoulder dystocia during labor is most likely related to which of the following?