A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take?

Offer to take the newborn to the nursery to finish his feeding.

Insist that the mother pick up the newborn to feed him.

Demonstrate how to hold the newborn and allow the client to practice.

Persuade the client to breastfeed the newborn to promote bonding.

Answer and Explanation

The Correct Answer is A

It is important to ensure the safety of the newborn, and in this situation, the adolescent mother is putting the newborn at risk by leaving him unattended while feeding. Offering to take the newborn to the nursery allows him to finish feeding in a safe environment while also allowing the nurse to assess his feeding and ensure he is receiving adequate nutrition. It is important to provide education to the mother on safe feeding practices, but at this moment, ensuring the safety of the newborn is the priority.

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Correct Answer is D

Explanation

Epidural analgesia during labor can cause temporary bladder dysfunction, which may result in an inability to void. This is due to the epidural medication affecting the nerves that control the bladder. If the client is unable to void, it can lead to bladder distention, which can be uncomfortable for the client and increase the risk of infection.

Tingling in her legs, abdominal cramps, and itching are common side effects of epidural analgesia, and can be addressed after the client's inability to void is addressed. The nurse can provide the client with education on these side effects and reassurance that they are typically temporary and should resolve on their own.

A. A newborn who has a short frenulum and is having difficulty breastfeeding B. A newborn who is 24 hr old and has not had a meconium stool C. A newborn who is 30 hr old and has blood-tinged discharge in her diaper D. A newborn who is 10 hr old and has new onset tachypnea

Correct Answer is D

Explanation

The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.

A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.

A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?

Correct Answer is D

Explanation

A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?

Correct Answer is D

Explanation

A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?

The nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccines? (Select all that apply.)

A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching?

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?