A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.
Which of the following actions should the nurse take
Diagnostic results
Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL
Platelet count 50,000 mm
WBC count 4,000 mm3
The Correct Answer is A
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, Sharp pelvic pain. An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tube. Sharp pelvic pain is a classic sign of an ectopic pregnancy, as the developing embryo can cause the tube to rupture or stretch, leading to pain. A scaphoid abdomen, elevated blood pressure, and bright red vaginal discharge are not typical manifestations of an ectopic pregnancy. 
Correct Answer is D
Explanation
Uterine rupture. When a client has had two prior cesarean births, she is at an increased risk for uterine rupture. Uterine rupture is a serious complication that can occur during labor, where there is a tear in the wall of the uterus. It can lead to significant blood loss for the mother and oxygen deprivation for the fetus. Other risk factors for uterine rupture include a previous uterine surgery, the use of labor-inducing drugs, and multiple gestations.
Failure to progress (choice A) refers to a labor that is not progressing as it should, and can be caused by a variety of factors, including fetal malposition or inadequate contractions. Abruptio placentae (choice B) refers to the separation of the placenta from the uterine wall before delivery, which can cause fetal distress and maternal hemorrhage. Precipitous labor (choice C) refers to a labor that progresses extremely quickly, with contractions lasting less than 3 hours from the onset of active labor. While precipitous labor can be associated with increased risk for perineal lacerations and postpartum hemorrhage, it is not typically associated with prior cesarean births.
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