A nurse is caring for a newborn.

The newborn was delivered via cesarean birth approximately 1 hr ago.

The Apgar Scores are 8 and 9. Vitamin K was administered in the left vastus lateralis.

The weight is 4337 grams (9 lb 9 oz), length 52 cm (20.5 in), and gestational age assessment of 39 weeks. The newborn is large for gestational age and noted to be jittery and have decreased muscle tone. Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn’s progress.

Check the newborn’s capillary blood glucose level.

Place the newborn under a radiant warmer.

Monitor the newborn’s temperature.

Monitor the newborn’s color and frequency of bowel movements.

Answer and Explanation

The Correct Answer is A,B,C

Choice A rationale

Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.

Choice B rationale

Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.

Choice C rationale

Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.

Choice D rationale

Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.

Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.

Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.

Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.

A. Evaluate the firmness of the uterus. B. Administer oxytocin infusion. C. Obtain a type and crossmatch. D. Initiate oxygen therapy by nonrebreather mask.

Correct Answer is A

Explanation

Choice A rationale

If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.

Choice B rationale

Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.

Choice C rationale

Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.

Choice D rationale

Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia. Which of the following observations should the nurse immediately report to the healthcare provider?

Correct Answer is C

Explanation

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

A nurse is caring for a newborn who is 4 hours old. Which condition poses the greatest risk to the newborn?

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. What is the most common risk factor for abruption?

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus. What actions should the nurse complete at this time?

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?