A newborn, who is 4 hours old, presents with the following symptoms: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonicity, and a weak cry.
What should the nurse do based on these findings?

Swaddle the infant in a warm blanket.

Document the findings in the record.

Place a pulse oximeter on the infant’s heel.

Obtain a heel stick blood glucose level.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale

Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.

Choice B rationale

A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.

Choice C rationale

A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.

Choice D rationale

Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.

A. Remind her to push three times with each contraction. B. Assessing the strength of uterine contractions. C. Re-evaluate the need for medication. D. Assisting her to maintain control.

Correct Answer is D

Explanation

Choice A rationale

While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.

Choice B rationale

Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.

Choice C rationale

Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.

Choice D rationale

Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Correct Answer is C

Explanation

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Correct Answer is D

Explanation

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

An 18-week pregnant client was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks about the next steps.What should the nurse advise?

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

A mother inquires about what to use when changing her newborn’s diaper. What should the nurse recommend to this mother?

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.What advice should the nurse give the client?