A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

The fetal head is in the left occiput posterior position.

The largest fetal diameter has passed through the pelvic outlet.

The posterior fontanel is palpable.

The lowermost portion of the fetus is at the level of the ischial spines.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

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Correct Answer is B

Explanation

Choice A rationale:

An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B rationale:

This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.

Choice C rationale:

A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.

Choice D rationale:

Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.

A. Check the newborn's temperature every 8 hr. B. Apply moisturizing lotion to the newborn's skin every 4 hr. C. Give the newborn 1 oz of glucose water every 4 hr. D. Reposition the newborn every 2 to 3 hr.

Correct Answer is D

Explanation

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

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A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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