A nurse is receiving a report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?

A newborn who has a respiratory rate of 34/min.

A newborn who has acrocyanosis.

A newborn who has caput succedaneum.

A newborn who has an axillary temperature of 36°C (96.8°F).

Answer and Explanation

The Correct Answer is D

Choice A rationale

A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.

Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.

Choice C rationale

Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.

Choice D rationale

An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.

A. Inform the client to expect to have dark-colored stools. B. Wear two pairs of gloves when handling the medication. C. Administer the medication subcutaneously. D. Instruct the client to use a condom during intercourse for the next 7 days.

Correct Answer is B

Explanation

Choice A rationale

Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.

Choice B rationale

Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.

Choice C rationale

Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.

Choice D rationale

While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.

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A nurse is receiving a report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.Which of the following actions should the nurse take?