A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?

A newborn who has subconjunctival hemorrhage of the left eye

A newborn who has overlapping suture lines

A newborn who has nasal flaring

A newborn who has rust stained urine

Answer and Explanation

The Correct Answer is C

A. Subconjunctival hemorrhage is common after vaginal delivery and usually harmless.
B. Overlapping suture lines are normal in newborns due to molding during birth.
C. Nasal flaring is a sign of respiratory distress and requires immediate assessment.
D. Rust-stained urine can be due to urate crystals and is usually benign in newborns.

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Correct Answer is B

Explanation

A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.

A. Assess for cervical dilation. B. Obtain a vaginal swab to test for ferning C. Administer oxytocin IV every hour D. Monitor fetal heart rate tracings

Correct Answer is D

Explanation

A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.

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A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is having a vacuum-assisted birth. Which of the following actions should the nurse take?

A nurse is reviewing the results of a biophysical profile for a client who is at 37 weeks of gestation. Which of the following findings indicates fetal well-being?

A nurse is teaching a client how to use a diaphragm. Which of the following statements should the nurse include in the teaching?

A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

A nurse is assessing a newborn who was exposed to heroin during pregnancy. Which of the following findings should indicate to the nurse that the newborn is experiencing neonatal abstinence syndrome? (Select all that apply.)

A nurse is caring for a newborn who is 5 days old. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hr. Which of the following diagnostic tests should the nurse anticipate?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)