Which action is most important for the nurse to implement?

Increase IV infusion rate.

Assess the vital signs.

Massage the fundus.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.

Choice B rationale

Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.

Choice C rationale

Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.

Choice D rationale

Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.

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Correct Answer is B

Explanation

Choice A rationale

Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.

Choice B rationale

Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.

Choice C rationale

Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.

Choice D rationale

Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.

A. Apply direct pressure to the caput succedaneum. B. Submit a request for a STAT Computerized Tomography (CT) scan of the head. C. Notify the pediatrician of the cephalhematoma. D. Assess neurological vital signs every 4 hours.

Correct Answer is C

Explanation

Choice A rationale

Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.

Choice B rationale

A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.

Choice C rationale

A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.

Choice D rationale

While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.

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Which action is most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

Correct Answer is C

Explanation

Which action should the nurse take?

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