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 D

Explanation

The correct answer is choice D. Cesarean delivery.A pregnant patient with genital herpes is at higher risk of transmitting the infection to the baby during vaginal delivery, especially if there is an active outbreak near the time of birth.This can cause serious complications for the baby, such as brain damage, eye problems, or even death.Therefore, a cesarean delivery is recommended to avoid contact between the baby and the genital lesions.

Choice A is wrong because forceps-assisted second stage of labor is not a complication of genital herpes.

It is a method of assisted delivery that may be used for various reasons, such as fetal distress, maternal exhaustion, or abnormal presentation.

Choice B is wrong because precipitous delivery, which means a very fast labor and delivery, is not a complication of genital herpes.

It may be caused by factors such as multiparity, strong contractions, or previous rapid deliveries.

Choice C is wrong because prolonged first phase of labor, which means a slow dilation of the cervix, is not a complication of genital herpes.

It may be caused by factors such as ineffective contractions, large fetal size, or malposition.

A. The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction. B. There is a six to ten beat-to-beat variability in the fetal heart rate. C. The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction. D. The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.

Correct Answer is A

Explanation

The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

Correct Answer is D

Explanation

A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

Correct Answer is A

Explanation

A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

A nurse is observing the internal fetal monitor readings of a laboring client.The fetal heart rate is between 130 and 138 beats per minute, with moderate beat-to-beat variability. How should the nurse interpret this finding?

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:

During the first postpartum day, a new mother is breastfeeding her infant.The client asks, “Since I don’t have any milk yet, why am I breastfeeding?” Which response by the nurse is most appropriate?

A nurse is reviewing laboratory results of a pregnant patient.Which result will require further assessment?

A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?

A client who is twO weeks postpartum calls the office and tells a nurse, "l am havinga small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A client who had pregnancy-induced hypertension (PIH) is now postpartum. A nurse should closely monitor this client for which complication?

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