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A nurse is assisting with the care of a newborn who was born at 39 weeks of gestation and is 36 hr old.

Assessment

Fontanels soft and flat

Head molded with caput succedaneum

Eyes symmetric, no discharge, sclera yellow Mucous membranes dry

Abdomen soft and rounded, bowel sounds present x 4 quadrants

Which of the following findings should the nurse report to the RN7 Select all that apply.

Glucose level

Mucous membrane assessment

Respiratory rate

Sclera color

Intake and output

Coombs test result

Heart rate

Head assessment finding

Answer and Explanation

Correct Answer : B,D,F,H

A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.

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Correct Answer is C

Explanation

A) Incorrect- the fundal height corresponds with approximately 16 weeks. At around 16 weeks of gestation, the fundal height is usually located approximately at the midpoint between the symphysis pubis (pubic bone) and the belly button (umbilicus). This measurement corresponds to the anatomical level of the uterus at this stage.
B) Incorrect- the fundal height corresponds with approximately 20 weeks. By 20 weeks of gestation, the fundus has typically reached the level of the umbilicus. The fundal height measurement is around the same level as the belly button.
C) Correct- the fundal height corresponds with approximately 32 weeks. Around 32 weeks of gestation, the fundal height has increased significantly compared to earlier stages of pregnancy. The fundus of the uterus is located above the belly button, and the measurement is typically about 32 centimeters (or roughly 12.6 inches) above the symphysis pubis.
D) Incorrect- the fundal height corresponds with approximately 24 weeks. Around 24 weeks of gestation, the fundal height is usually about 1 to 2 fingerbreadths above the
umbilicus. This represents the ongoing upward growth of the uterus as the pregnancy progresses.
E) Incorrect- the fundal height corresponds with approximately 18 weeks. At around 18 weeks of pregnancy, the fundal height is typically located just above the pubic bone, below the belly button (umbilicus). The fundus of the uterus is still relatively low in the abdomen at this point. The fundal height measurement at 18 weeks is usually around the midpoint between the symphysis pubis (pubic bone) and the belly button.

A. Have a high-fat snack before going to bed. B. Limit snacks between meals. C. Drink 240 mL (8 oz) of water with each meal. D. Eat a slice of dry toast before getting out of bed.

Correct Answer is D

Explanation

A) Incorrect- Having a high-fat snack before bed might exacerbate nausea. It's generally recommended to have a light snack if needed.
B) Incorrect- Eating small, frequent snacks between meals can help manage nausea by preventing an empty stomach.
C) Incorrect- Drinking water with meals might not necessarily help with nausea and might worsen the feeling of fullness.
D) Correct - "Eat a slice of dry toast before getting out of bed" can help alleviate morning sickness in the first trimester. Eating a small, bland snack before rising can prevent an empty stomach, which can contribute to nausea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in obtaining the fundal height measurement for a client who is at 32 weeks of gestation. Which of the following images indicates where the nurse should expect the client's fundus to be located?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about how to minimize nausea in the first trimester of pregnancy. Which of the following instructions should the nurse give to the client?

Correct Answer is D

Explanation

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A nurse is reinforcing teaching about home safety precautions with the guardian of a newborn. Which of the following instructions should the nurse include?

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