A nurse is assessing a newborn.
Which finding may indicate a problem?

The newborn’s nostrils flare slightly during respiration.

The newborn’s hands and feet are blue and feel cool.

The newborn’s eyes move randomly when his head is turned to the side.

The newborn’s tongue thrusts forward when it is lightly touched.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The newborn’s nostrils flare slightly during respiration. This is a sign of respiratory distress in a newborn.

Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.

Choice B is wrong because the newborn’s hands and feet are blue and feel cool. This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.

It usually resolves within 24 to 48 hours after birth.

Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side. This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.

It usually disappears by 6 months of age.

Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched. This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.

It usually fades by 4 months of age.

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Correct Answer is B

Explanation

The correct answer is choice B. The client should avoid sexual intercourse.Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor.The client should also avoid activities that may cause dehydration, infection, or stress.

Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home.Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.

Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home.The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.

Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home.Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.

A. breast care teaching because she is predisposed to mastitis. B. frequent uterine fundal assessments because she is at risk for developing a prolapsed uterus. C. a strict toileting schedule because she is prone to developing a urinary tract infection. D. an “as needed” order for an analgesic because she is likely to have pain.

Correct Answer is B

Explanation

The correct answer is choice B. A multipara is a woman who has given birth more than once.

After delivery, the uterus contracts to return to its normal size and position.

However, in multiparas, the uterine muscles may be weaker and less able to contract effectively.

This can lead to a condition called uterine atony, where the uterus does not contract enough to prevent bleeding.

Uterine atony can also cause the uterus to descend into the vagina, which is called a prolapsed uterus.

Therefore, multiparas need frequent uterine fundal assessments to monitor the tone and position of the uterus and prevent complications.

Choice A is wrong because breast care teaching is important for all postpartum women, regardless of parity.

Mastitis is an inflammation of the breast tissue that can occur in any woman who is breastfeeding or not.

It is not more common in multiparas.

Choice C is wrong because a strict toileting schedule is not necessary for multiparas.

Urinary tract infections (UTIs) are caused by bacteria entering the urinary tract, usually from the urethra.

UTIs are not more common in multiparas, unless they have other risk factors such as catheterization, diabetes, or sexual activity.

Choice D is wrong because an “as needed” order for an analgesic may not be adequate for multiparas.

Pain after delivery can vary depending on the type and duration of labor, the size and position of the baby, and the use of anesthesia or episiotomy.

Multiparas may experience more pain due to stretching of the pelvic muscles and ligaments, or due to afterpains, which are contractions of the uterus that occur after delivery.

Therefore, multiparas may need regular doses of analgesics to manage their pain effectively.

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A nurse is assessing a newborn. Which finding may indicate a problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client treated for preterm labor is to be discharged to home. Which instruction should a nurse include in this client’s discharge plan? The client should:.

Correct Answer is B

Explanation

In planning the postpartum care of a multipara who had a normal pregnancy, labor, and delivery, which factor should be considered? The client needs to have:

Correct Answer is B

Explanation

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A nurse is assessing a newborn.
Which finding may indicate a problem?