During an observational experience in labor and delivery, the student nurse recognizes that thick meconium is present in the amniotic ﬂuid. Upon delivery of the newborn, the student nurse understands that there are signs that indicate that the newborn will need resuscitation. These signs are:
Select one:

Central cyanosis and poor tone.

Heart rate of 160 beats per minute and spitting up mucus.

Crying with respirations of greater than 60 breaths per minute.

Blue hands and feet but lips that are slowly pinking up.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.

Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic ﬂuid, which can be cleared by suctioning or burping.

Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.

Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

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Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

A. Provide compassionate and accurate information throughout the process and support them to make their own decisions. B. Inquire about the names they have chosen for their baby to get their mind oﬀ their stress. C. Express sympathy and provide directive advice to the couple about what they should do. D. Refer them to a marriage counselor in the same building to help them with the decisions.

Correct Answer is A

Explanation

Choice A Reason: Provide compassionate and accurate information throughout the process and support them to make their own decisions. This is a therapeutic strategy that demonstrates empathy, honesty, and advocacy for the couple. It also helps them understand their options, risks, benefits, and alternatives, and encourages them to participate in their care.

Choice B Reason: Inquire about the names they have chosen for their baby to get their mind oﬀ their stress. This is a non-therapeutic strategy that avoids addressing the couple's concerns, minimizes their feelings, and may create false hope or unrealistic expectations.

Choice C Reason: Express sympathy and provide directive advice to the couple about what they should do. This is a non-therapeutic strategy that shows pity, imposes personal values, and undermines the couple's self-determination.

Choice D Reason: Refer them to a marriage counselor in the same building to help them with the decisions. This is a non-therapeutic strategy that implies that the couple has marital problems, shifts responsibility, and may create resentment or resistance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Correct Answer is D

Explanation

A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic? Select one:

Correct Answer is A

Explanation

If a woman has a pre-existing condition of diabetes, the nurse knows that she would be at risk for what symptom(s) during her pregnancy? Select one:

After the birth of a newborn, the nursing intervention that most eﬀectively promotes parental atachment is: Select one:

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

A term newborn weighs 4 pounds 5 ounces. The nurse assesses that this newborn is small for gestational age (SGA). The nurse knows that teaching has been eﬀective when the parents state: Select one:

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? Select one:

An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action? Select one: