A nurse is caring for a newborn immediately following birth.

Exhibits

The nurse is assessing the newborn 24 hr later.

How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Findings 24 hr later:

Color: Consistent with genetic background.

Axillary temperature 36.3° C (97.4°F). Reflex irritability: cry.

Muscle tone: flaccid.

Respiration effort: good cry.

Heart rate 140/min.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

A. Dim the lights in the client's room. B. Ensure the call button is within the client's reach. C. Pad the side rails of the client's bed. D. Place suction equipment at the client's bedside.

Correct Answer is C

Explanation

Choice A rationale:
Dimming the lights in the client’s room can help create a calming environment but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice B rationale:
Ensuring the call button is within the client’s reach is important for patient safety and communication, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice C rationale:
Padding the side rails of the client’s bed is the priority when implementing seizure precautions for a client with preeclampsia. This is to protect the client from injury during a seizure.
Choice D rationale:
Placing suction equipment at the client’s bedside is important for maintaining airway patency after a seizure, but it is not the priority when implementing seizure precautions for a client with preeclampsia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

Correct Answer is D

Explanation

A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

Correct Answer is C

Explanation

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?