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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Late decelerations on the fetal monitor tracing indicate uteroplacental insufficiency, which can compromise fetal oxygenation. When membranes rupture and late decelerations occur, it's essential to take immediate action to improve fetal oxygenation.
Turning the client onto her side can help improve uteroplacental perfusion by relieving pressure on the vena cava and increasing blood flow to the uterus. This is the initial recommended intervention to optimize fetal oxygenation in the presence of late decelerations.
B. Increasing IV fluid infusion rate may be considered to optimize maternal hydration and potentially improve uteroplacental perfusion. However, it may not be the first action taken in response to late decelerations.
C. Palpating the client's uterus can provide information about uterine activity and may help assess for uterine hyperstimulation, which can contribute to fetal distress. However, in the context of late decelerations, the priority is to address potential uteroplacental insufficiency and optimize fetal oxygenation.
D. Administering oxygen to the client helps increase maternal oxygenation, which in turn improves fetal oxygenation. Oxygen administration is done after positing the client on to the lateral position.

A. Excessive uterine enlargement B. Rapid decline in human chorionic gonadotropin (hCG) levels C. Profuse, clear vaginal discharge D. Irregular fetal heart rate

Correct Answer is A

Explanation

A hydatidiform mole (molar pregnancy), is a type of gestational trophoblastic disease characterized by abnormal and rapid growth of trophoblastic cells leading to uterine size that is large for gestational age
B. Molar pregnancy leads to elevated hCG levels not a decline.

C. Vaginal discharge in molar pregnancy is bloody with grape like vesicles.

D. Molar pregnancy does not yield into a viable fetus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Correct Answer is A

Explanation

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A nurse receives a mother and baby in postpartum. The baby is approximately 2 hours old. During the assessment of the baby the nurse recognizes the following symptoms of transient tachypnea of the newborn except for-

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?