A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?

"Swaddle your baby tightly with his legs extended before laying him down to sleep.".

"Notify your baby's pediatrician if he urinates less than six times a day.".

"Retract the foreskin to clean your baby's penis during each bath.".

"Place triple antibiotic ointment on your baby's umbilical cord twice per day."

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.

Choice B rationale:

This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.

Choice C rationale:

It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.

Choice D rationale:

Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.

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Correct Answer is C

Explanation

Choice A rationale:

Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.

Choice B rationale:

Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.

Choice C rationale:

Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.

Choice D rationale:

Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.

A. Blood pressure 136/88 mm Hg. B. Moderate fetal heart rate variability. C. Respiratory rate 100/min. D. Urinary output 120 mL in 2 hr.

Correct Answer is C

Explanation

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

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A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect?

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

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A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?

A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer?