A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A newborn who is 18 hr post-delivery and has acrocyanosis

A newborn who is 24-hr post-delivery and has not passed meconium

A newborn who is 24 hr post-delivery and has persistent tachycardia with a heart rate of 180 bpm

A newborn who is 24 hr post-delivery and has not voided

Answer and Explanation

The Correct Answer is C

A.   Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B.   Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D.   Not voiding within the first 24 hours may be normal, but it should be monitored.

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Correct Answer is C

Explanation

A. Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.

A. Uterine tetany and overproduction of oxytocin B. Multiple gestation and postpartum hemorrhage C. Retained placental fragments and infection D. Postpartum hemorrhage and infection

Correct Answer is C

Explanation

A. Uterine tetany and overproduction of oxytocin are not typically associated with subinvolution.
B. Multiple gestation and postpartum hemorrhage may contribute to uterine atony but not necessarily subinvolution.
C. The most common causes of subinvolution are retained placental fragments and infection.
D. Postpartum hemorrhage may contribute to uterine atony but is not a direct cause of subinvolution.

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A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?

Correct Answer is C

Explanation

What are the most common causes for subinvolution of the uterus?

Correct Answer is C

Explanation

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

A new mother asks the nurse what the "experts say" about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process?

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?