A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

Platelets 200,000/mm3

Bilirubin 19 mg/dL

Blood glucose 45 mg/dL

Hemoglobin 22 g/dL

Answer and Explanation

The Correct Answer is B

- A) A platelet count of 200,000/mm3 is within the normal range for a newborn and does not require immediate intervention.
- B) A bilirubin level of 19 mg/dL is high and suggests the possibility of hyperbilirubinemia, which can lead to jaundice and, in severe cases, kernicterus, a form of brain damage. This is a critical value that requires immediate attention.
- C) A blood glucose level of 45 mg/dL is on the lower end of the normal range, but it is not as immediately concerning as the elevated bilirubin level. Monitoring and appropriate feeding should address this issue.
- D) A hemoglobin level of 22 g/dL is high, indicating polycythemia, which can be a risk factor for hyperviscosity syndrome. However, it is not as urgent as the bilirubin level of 19 mg/dL. Monitoring and partial exchange transfusion may be considered if symptoms develop.

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Correct Answer is D

Explanation

A. Applying an ice pack may provide temporary relief from pain and swelling, but in this case, since the pain is unrelieved, a warm sitz bath would be more appropriate to promote relaxation and healing of the perineal area.
B. Applying a hot pack to the perineum may increase inflammation and discomfort rather than providing relief.
C. Providing a squeeze bottle of antiseptic solution may help with perineal hygiene but will not directly address the unrelieved pain from the episiotomy.

D. Offering a warm sitz bath can help soothe the perineal area, promote healing, and provide relief from episiotomy pain by increasing blood flow to the area and relaxing the muscles.

A. Encourage the client to move to the left lateral position. B. Assist the client to the bathroom to void. C. Ask the client to rate her pain. D. Encourage the client to perform Kegel exercises.

Correct Answer is A

Explanation

A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.

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A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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