A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.At 6 hours post-partum, the client is anxious and restless.
On further assessment, a large perineal hematoma is seen.
She is unable to urinate.
After notifying the physician, the nurse should plan to:

Insert a Foley catheter.

Instruct the client on using a Sitz Bath when she voids.

Monitor the fundal height.

Apply a heating pad to the area.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Inserting a Foley catheter can relieve the bladder and provide an opportunity to monitor urinary output, which is essential for assessing the patient's condition with a perineal hematoma.

Choice B rationale

A Sitz bath may help with pain relief and hygiene but does not address the immediate concern of urinary retention and assessment for injury.

Choice C rationale

Monitoring the fundal height is important but does not address the urgent need to relieve the patient's inability to urinate.

Choice D rationale

Applying a heating pad to the area may help with pain, but it does not address the immediate problem of urinary retention due to the hematoma.

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Correct Answer is D

Explanation

Choice A rationale

Positive Moro and stepping reflexes are normal findings in newborns and are not specifically associated with dehydration or SGA.

Choice B rationale

Scant vernix is common in full-term babies and not indicative of SGA or dehydration.

Choice C rationale

Blood glucose levels provided are within normal range for newborns and do not indicate dehydration.

Choice D rationale

Tenting of the skin and dry lips are signs of dehydration, which can be associated with SGA newborns due to insufficient fluid intake. .

A. Moro. B. Stepping. C. Rooting. D. Babinski.

Correct Answer is C

Explanation

Choice A rationale

The Moro reflex is a startle response in newborns and does not assist in promoting latching during breastfeeding.

Choice B rationale

The stepping reflex, also known as the walking reflex, involves a newborn making stepping movements when held upright and does not contribute to latching during breastfeeding.

Choice C rationale

The rooting reflex causes a newborn to turn their head toward a touch on their cheek and begin sucking movements, which is crucial for promoting latching during breastfeeding.

Choice D rationale

The Babinski reflex involves the toes fanning out when the sole of the foot is stroked and is unrelated to latching during breastfeeding. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 40-week small for gestational age (SG

Correct Answer is D

Explanation

A nurse is assisting a client with breastfeeding.Which of the following reflexes will promote the newborn to latch?

Correct Answer is C

Explanation

A 35-year-old patient is getting her labs drawn at the six weeks post-partum check-up. Upon assessment, the nurse notes swelling in the patient's left leg, and the patient reports pain and tenderness in the calf.The nurse knows which lab results are responsible?

The nurse develops a teaching plan for a 24-hour vaginal postpartum client with a firm fundus, scant lochia, and a 4th degree laceration.Her hemoglobin level is 10.0 gm/dl, and hematocrit is 30%. The mother is breastfeeding.Which medication would the nurse expect to be contraindicated?

The nurse calculates the 1-minute Apgar score of a neonate with the following characteristics to be: Heart rate 60; weak cry, partial flexion of extremities; weak suck; gray color.

The RN has received a hand-off report.Which client does the RN need to see first?

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

The nurse is assessing the client's transition to the taking-hold phase after an uncomplicated vaginal birth.Which behavior by the mother best indicates this transition is occurring?

You are required to administer 3,800 units of Heparin sodium dose subcutaneously (SQ) to a mother. The pharmacy sends a 10,000 units in a 5ml vial. How many mls will the nurse administer?

A neonatologist prescribes gentamicin for a 2-day-old, septic preterm infant who weighs 4300 grams. The dosage of gentamicin for babies less than 1 week of age is 2 mg/kg q 12 hours. The dose on hand is 20 mg per 1 ml. The nurse calculates the safe dose of this medication to be. ml. in 12 hours.