A nurse in a newborn nursery is receiving change-of-shift report for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who is 24 hr old and has not had a meconium stool.
A newborn who has a short frenulum and is having difficulty breastfeeding.
A newborn who is 10 hr old and has onset tachypnea.
A newborn who is 30 hr old and has blood-tinged discharge in her diaper.
The Correct Answer is C
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Magnesium sulfate is used to prevent seizures in women with preeclampsia.
However, taking too much magnesium can be life-threatening to both mother and child.
In women, one of the most common symptoms of magnesium toxicity is muscle weakness12.
Choice B is not an answer because increased fetal movement is not a symptom of magnesium toxicity.
Choice C is not an answer because increased respiratory rate is not a symptom of magnesium toxicity.
Choice D is not an answer because increased urinary output is not a symptom of magnesium toxicity.
Correct Answer is D
Explanation
The nurse should instruct the client to have her provider refit her for a diaphragm.
After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm.
It is recommended that a woman be refited for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.
Choice A is incorrect because oil-based lubricants can damage the diaphragm and reduce its effectiveness.
Water-based lubricants should be used instead.
Choice B is incorrect because storing a diaphragm in sterile water is not necessary.
The diaphragm should be washed with mild soap and water after each use and air-dried before being stored in its case.
Choice C is incorrect because the diaphragm should be kept in place for at least 6 hours after intercourse, not 4 hours.
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