A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

Uterine atony

Thrombophlebitis

Puerperal infection

Retained placental fragments

Answer and Explanation

The Correct Answer is A

A.   Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B.   Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C.   Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D.   Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this complication.

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Correct Answer is D

Explanation

A. Administering thyroid hormone replacement is not indicated for phenylketonuria (PKU). PKU is a metabolic disorder involving the inability to metabolize phenylalanine, an amino acid, and it does not involve thyroid dysfunction.
B. Blood glucose monitoring is not directly related to the management of PKU. In PKU, the focus is on monitoring and restricting phenylalanine intake, not blood glucose levels.
C. Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D. Initiating a controlled low-protein diet is the cornerstone of management for PKU. This diet restricts phenylalanine intake, which is essential for preventing neurological damage and
developmental delays in affected infants.

A. Monitor the newborn's blood pressure. B. Obtain blood glucose by heel stick. C. Place the newborn in a radiant warmer. D. Initiate phototherapy.

Correct Answer is B

Explanation

A. Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.

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A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?