A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which of the following findings indicates a decline in the newborn's status?

Apneic episode less than 15 seconds

Fine crackles

Oxygen saturation of 89%

Nasal flaring

Answer and Explanation

The Correct Answer is C

Rationale:

A. An apneic episode less than 15 seconds may be considered within normal limits for a newborn and does not necessarily indicate a decline in status.

B. Fine crackles may indicate fluid in the lungs but are not specific to a decline in the newborn's status.

C. An oxygen saturation of 89% indicates hypoxemia, which is a significant concern and suggests respiratory compromise. It indicates a decline in the newborn's status and requires immediate intervention to improve oxygenation.

D. Nasal flaring is a sign of respiratory distress but may not be as concerning as a low oxygen saturation level in this context. It indicates increased work of breathing but does not provide direct information about oxygenation status.

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Correct Answer is D

Explanation

Rationale:

A. Tubal ligation does not typically affect the length of menstrual periods.

B. While tubal ligation may prevent pregnancy, it does not directly impact premenstrual tension.

C. Hormone replacement therapy is not typically indicated following tubal ligation unless there are other underlying medical reasons for hormone imbalance.

D. "Ovulation will remain the same" is correct. Tubal ligation prevents pregnancy by blocking the fallopian tubes, but it does not affect ovulation. Therefore, the client will continue to ovulate normally after the procedure.

A. Peripheral edema 2+ bilateral lower extremities B. Blood pressure 136/6 mm Hg C. Lateral deviation of the uterus D. Pain rating of 3 on a scale of 0 to 10 E. Deep tendon reflexes 1+ F. Breasts soft G. Large amount of lochia rubra H. Uterine tone soft

Correct Answer is ["C","G","H"]

Explanation

A. Peripheral edema 2+ bilateral lower extremities - Peripheral edema is common postpartum and does not typically require immediate follow-up unless it is associated with other concerning signs or symptoms.
B. Blood pressure 136/6 mm Hg - The blood pressure provided appears to be incorrect, as the diastolic pressure is unusually low. However, given the options provided, blood pressure is not explicitly mentioned in the scenario as a critical factor requiring immediate follow-up.
C. Lateral deviation of the uterus - Lateral deviation of the uterus suggests uterine atony, a potential complication of postpartum hemorrhage, requiring immediate follow-up and intervention to prevent further complications.
D. Pain rating of 3 on a scale of 0 to 10 - While increased pain should be addressed, it does not necessarily indicate an emergency situation requiring immediate follow-up compared to other findings such as uterine deviation or excessive bleeding.
E. Deep tendon reflexes 1+ - This finding is within normal limits and does not require immediate follow-up.
F. Breasts soft - Soft breasts are expected in the postpartum period and do not typically require immediate follow-up unless associated with other concerning signs or symptoms.

G. Large amount of lochia rubra - A large amount of bright red lochia could indicate postpartum hemorrhage, necessitating immediate follow-up and intervention to prevent further complications.
H. Uterine tone soft - Soft uterine tone suggests uterine atony, which is a potential complication requiring immediate follow-up and intervention to prevent excessive bleeding.

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A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which of the following findings indicates a decline in the newborn's status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["C","G","H"]

Explanation

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