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. "Let me check your vaginal discharge just to make sure everything is fine." While it's important to monitor for abnormal discharge (such as signs of infection or retained placental tissue), this response does not address the cause of the contractions, which are a normal postpartum occurrence.

B. "Your body is responding to the events of labor, just like after a tough workout." This statement doesn't accurately explain the specific cause of the contractions, which are related to hormonal changes after childbirth rather than residual effects of labor itself.

C. "Your uterus is still shrinking in size; that's why you're feeling this pain." While it’s true that the uterus is shrinking (involution), the primary reason for the contraction-like pain is the release of oxytocin during breastfeeding, not simply the shrinking of the uterus.

D. "The baby's sucking releases a hormone that causes the uterus to contract." This is the correct answer. When a newborn suckles at the breast, it stimulates the release of oxytocin, a hormone that causes the uterus to contract. These contractions are known as "afterpains" and are more common in women who have had multiple pregnancies. They help the uterus return to its normal size after delivery.

A. difficulty in arousing B. deep tendons reflexes 2+ C. urinary output of 20 mL per hour D. respiratory rate of 10 breaths/minute

Correct Answer is B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

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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 client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

Correct Answer is D

Explanation

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

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

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

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

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A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?