A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?

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

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

A newborn who is 12 hours post-delivery and has a temperature of 37.5°C (99.5°F)

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

Answer and Explanation

The Correct Answer is D

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.

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Correct Answer is B

Explanation

Choice A rationale
Repaglinide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice B rationale
Insulin is the most common medication used to control blood sugar in pregnant women with gestational diabetes when diet and exercise are not enough.
Choice C rationale
Acarbose is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice D rationale
Glipizide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.

A. Assist the family to identify prior use of positive coping skills in family crises. B. Anticipate a prescription by the provider for an antidepressant. C. Ask the client if she has considered harming her newborn. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is C

Explanation

Choice A rationale

Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it’s not the priority action in this situation.
Choice B rationale
Anticipating a prescription by the provider for an antidepressant might be necessary if the client is diagnosed with postpartum depression. However, the nurse first needs to assess the risk to the client and her newborn.
Choice C rationale
Asking the client if she has considered harming her newborn is the priority action. This question is crucial in assessing for postpartum depression and the safety of the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the priority action when the client is expressing feelings of sadness and lack of energy.

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A nurse in the newborn unit is caring for several infants. Which of the following situations requires the nurse's immediate attention and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

Correct Answer is B

Explanation

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”, sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is C

Explanation

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A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?