A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Administer oxytocin.

Observe for pooling of blood under the buttocks.

Check the client's blood pressure.

Massage the client's fundus.

Answer and Explanation

The Correct Answer is D

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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Correct Answer is D

Explanation

Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.

Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.

Mucus drainage does not interfere with breathing unless it is excessive or thick.

Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.

Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.

A. Monitor the newborn's blood glucose level hourly. B. Apply lotion to the newborn's skin twice per day. C. Encourage the newborn to breastfeed every 2 hr. D. Maintain the newborn in a prone position.

Correct Answer is C

Explanation

Encourage the newborn to breastfeed every 2 hr. This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.

Choice A is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.

Choice B is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.

Choice D is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.

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A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

Correct Answer is D

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

To protect newborns from infection while in the nursery, the nurse plans to:

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.