When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?

Have you passed any clots?

Do you have to go to the bathroom?

When was the last time you changed your pad?

Are you having any cramping?

Answer and Explanation

The Correct Answer is A

A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.

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Correct Answer is D

Explanation

A. Keep eye shields on at all times, including when feeding. Incorrect because while eye protection is crucial under the lights, they can be removed during feedings to allow for parent-infant bonding and eye contact.
B. Routinely monitor temperature while the infant is in the crib. Incorrect, because temperature should be closely monitored while the infant is under phototherapy due to potential changes in body temperature caused by the exposure.
C. Tightly swaddle the infant in a blanket. Incorrect, as this would reduce the amount of skin exposed to the phototherapy lights and decrease the treatment's effectiveness.
D. Expose as much of the infant's skin to the lights as possible. Phototherapy is most effective when as much skin as possible is exposed to the lights because it allows for maximum light absorption and more effective bilirubin breakdown.

A. The newborn who has cyanotic hands and feet. B. The newborns whose head turns toward the cheek being stroked C. The newborn whose toes curl when the lateral heel is stroked D. The newborn who extends the arms when hearing a loud noise

Correct Answer is A

Explanation

A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.

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When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights. Which of the following is an appropriate intervention for this infant?

Correct Answer is D

Explanation

Which newborn assessment finding would require the nurse to report to the health care provider?

Correct Answer is A

Explanation

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