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16. A nurse is caring for a newborn who is 4 hr old.
Nurses' Notes
Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
Newborn's respirations are shallow and irregular.
Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
Breastfed vigorously for 30 min.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect
16. A nurse is caring for a newborn who is 4 hr old.
Nurses' Notes
Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
Newborn's respirations are shallow and irregular.
Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
Breastfed vigorously for 30 min.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect
The Correct Answer is ["Moro reflex color of extremities head assessment maternal urine toxicology screen gluteal folds"]
Subgaleal hemorrhage is a rare but potentially serious condition in newborns characterized by bleeding beneath the scalp's galea aponeurotica, a fibrous tissue layer between the scalp and the skull.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
Station refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis, which serve as a reference point during labor.
Correct Answer is D
Explanation
A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH
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