A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Acrocyanosis of the extremities

Murmur at the left sternal border

Substernal chest retractions while sleeping

Positive Babinski reflex

Answer and Explanation

The Correct Answer is C

The correct answer is C.

A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.

B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.

C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.

D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.

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Correct Answer is A

Explanation

A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.

B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.

C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.

D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.

A. September 3rd B. September 20th C. August 3rd D. August 20th

Correct Answer is A

Explanation

Nägele's rule is a method used to estimate the expected date of delivery (EDD) for a pregnant woman. To use Nägele's rule, you start with the first day of the last menstrual period (LMP), add one year, subtract three months, and add seven days.

In this case:

LMP: November 27th

Add one year: November 27th of the following year

Subtract three months: August 27th

Add seven days: September 3rd

Therefore, according to Nägele's rule, the expected date of birth is September 3rd

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A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

A nurse is calculating a client's expected date of birth using Nägele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

Correct Answer is A

Explanation

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