A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?

Encourage the client to nurse more frequently so her milk will come in

Report the client's temperature elevation

Ask the client to empty her bladder

Increase IV fluids

Answer and Explanation

The Correct Answer is C

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

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Correct Answer is B

Explanation

Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or ilotycin can prevent GON and other less severe eye infections by killing the bacteria.

Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.

Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.

A. The ductus arteriosus expands to allow more blood to enter the lungs B. The foramen ovale closes, preventing blood exchange from right to left in the heart C. The umbilical vein that carried oxygenated blood in utero becomes the ascending aorta entering the right atrium D. The ductus venosus shunts oxygenated aortic blood to the lungs.

Correct Answer is B

Explanation

The foramen ovale closes, preventing blood exchange from right to left in the heart. This is because the foramen ovale is a fetal shunt that allows blood to bypass the lungs and flow from the right atrium to the left atrium. After birth, when the baby starts to breathe air, the lungs expand and the pulmonary resistance decreases. This causes an increase in blood flow and pressure in the left atrium, which pushes the foramen ovale closed. This prevents blood from mixing between the right and left sides of the heart and allows oxygenated blood to circulate to the body¹².

Choice A is not correct because the ductus arteriosus does not expand to allow more blood to enter the lungs. The ductus arteriosus is another fetal shunt that

connects the pulmonary artery to the aorta. It allows blood to bypass the lungs and flow from the right ventricle to the aorta. After birth, when the baby starts to breathe air, the oxygen concentration in the blood increases and causes the ductus arteriosus to constrict and close. This increases blood flow to the lungs and decreases blood flow to the aorta.

Choice C is not correct because the umbilical vein that carried oxygenated blood in utero does not become the ascending aorta entering the right atrium. The umbilical vein is a fetal vessel that carries oxygenated blood from the placenta to the fetus. It connects to either the portal vein or the ductus venosus, which then drains into the inferior vena cava. After birth, when the umbilical cord is clamped and cut, the umbilical vein collapses and becomes a fibrous cord called ligamentum teres hepatis.

Choice D is not correct because the ductus venosus does not shunt oxygenated aortic blood to the lungs. The ductus venosus is another fetal vessel that connects the umbilical vein to the inferior vena cava. It allows some of the oxygenated blood from the placenta to bypass the liver and enter directly into the systemic circulation. After birth, when the umbilical cord is clamped and cut, the ductus venosus closes and becomes a fibrous cord called ligamentum venosum.

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.

Correct Answer is B

Explanation

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the body?

Correct Answer is B

Explanation

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?