A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?
The newborn's cord stump is still attached after 1 week.
The newborn sleeps 16 hr a day.
The newborn has fewer than four wet diapers in 24 hr
The newborn has loose stools.
The Correct Answer is C
A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["B","E"]
Explanation
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
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