A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

Decreased heart rate

Chin quivering

Pinpoint pupils

Slowed respirations

Answer and Explanation

The Correct Answer is B

A. Decreased heart rate: This is not typically an indication of pain in a newborn. Pain can often lead to an increased heart rate as the body responds to stress or discomfort.

B. Chin quivering: This is a common sign of pain in newborns. When infants experience pain, they may exhibit facial expressions such as quivering of the chin, furrowing of the brow, or grimacing.

C. Pinpoint pupils: Pinpoint pupils are not a typical sign of pain in a newborn. This may be associated with certain medications or conditions affecting the nervous system, but it is not a direct indicator of pain.

D. Slowed respirations: While pain can sometimes cause changes in respiratory patterns, slowed respirations alone may not be a reliable indicator of pain in a newborn. Other signs, such as facial expressions or crying, are often more indicative of pain.

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Correct Answer is A

Explanation

The correct answer is A.

A. Swelling of the face: Facial swelling, especially sudden or severe swelling, could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ dysfunction. Any new or significant facial swelling should be promptly reported to the healthcare provider for evaluation.

B. Varicose veins in the calves: Varicose veins are a common occurrence during pregnancy due to increased pressure on the veins. While they can cause discomfort, they are generally not considered a significant concern unless there are signs of complications, such as inflammation or blood clots.

C. Nonpitting 1+ ankle edema: Mild ankle edema is relatively common during pregnancy and may not be concerning unless it becomes severe, sudden, or is associated with other symptoms. Nonpitting edema is generally less concerning than pitting edema but should still be monitored.

D. Hyperpigmentation of the cheeks: Hyperpigmentation, often referred to as the "mask of pregnancy" or melasma, is a common and benign condition during pregnancy. While it may be bothersome to some individuals, it is not typically a concern that requires immediate reporting to the provider.

A. Administer oxygen to the client B. Turn the client onto her side C. Increase the client's IV fluid infusion rate D. Palpate the client's uterus

Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

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A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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