A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

A newborn who has blue hands and feet with an axillary temperature of 36.6°C (97.9°F)

A newborn who has lost 12% of her birth weight

A newborn who is 24 hr post-circumcision and has yellow exudate

A newborn who has a blood glucose level of 63 mg/dL

Answer and Explanation

The Correct Answer is A

A. The newborn with blue hands and feet (acrocyanosis) along with a normal axillary temperature of 36.6°C (97.9°F) could indicate a need for further assessment. While acrocyanosis can be normal in newborns, it is essential to monitor for any signs of respiratory distress or circulatory issues. Since this newborn is exhibiting a potential sign of compromised circulation, this infant should be attended to first.

B. A newborn who has lost 12% of her birth weight is concerning, as significant weight loss in newborns can indicate feeding problems or other underlying issues. However, this would not take precedence over potential acute issues like those indicated in option A.

C. A newborn who is 24 hours post-circumcision with yellow exudate is expected to have some discharge as part of the healing process. If the exudate is not foul-smelling and there are no signs of infection, this is typically a normal finding.

D. A newborn with a blood glucose level of 63 mg/dL is within the normal range for newborns, as acceptable levels are typically above 40 mg/dL. Therefore, this does not require immediate attention.

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Correct Answer is D

Explanation

A. Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B. Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C. Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D. Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.

A. Increased uterine tone B. Blood pressure 120/74 mm Hg C. Decreased perineal edema D. Urinary output 100 mL/hr

Correct Answer is A

Explanation

A. Increased uterine tone: Methylergonovine is a medication used to prevent or treat postpartum hemorrhage. It works by causing uterine contractions, which helps to control bleeding. An indication that the medication is effective would be an increase in uterine
tone, as this signifies that the uterus is contracting appropriately.
B. Blood pressure 120/74 mm Hg: While a blood pressure of 120/74 mm Hg is within the normal range, it does not specifically indicate the effectiveness of methylergonovine.
Blood pressure is an important parameter to monitor, but it alone does not determine the effectiveness of the medication.
C. Decreased perineal edema: Decreased perineal edema may be a positive sign for the client's overall recovery, but it is not a direct indicator of methylergonovine's
effectiveness. Perineal edema is not a primary concern addressed by this medication.
D. Urinary output 100 mL/hr: Urinary output of 100 mL/hr is an important parameter to monitor for renal function. However, it does not specifically indicate the effectiveness of methylergonovine in preventing or treating postpartum hemorrhage. Urinary output is crucial for assessing kidney function and fluid balance but is not directly related to the action of this medication.

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A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postpartum. Which of the following findings should alert the nurse to the possibility of a puerperal infection?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is postpartum and has received methylergonovine. Which of the following findings should indicate to the nurse that the medication was effective?

Correct Answer is A

Explanation

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