Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.

Insert an orogastric decompression tube with low wall suction.

Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.

Administer nitric oxide inhalation therapy to the newborn.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Measuring the abdominal circumference at the level of the newborn's umbilicus every 12 hr is a critical action in this scenario. The newborn has necrotizing enterocolitis (NEC), a serious gastrointestinal condition, and measuring abdominal circumference can help monitor for changes in abdominal distention, which is a sign of NEC progression.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction may not be the most appropriate action for a newborn with NEC. While decompression tubes can be used in some cases of NEC, their insertion should be guided by specific clinical indications, and not all cases require them.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated for NEC. NEC requires specialized medical management and treatment, which may include bowel rest and other interventions, but providing iron-rich formula is not one of them.

Choice D rationale:

Administering nitric oxide inhalation therapy is not relevant to the management of NEC. Nitric oxide inhalation therapy is used for respiratory conditions, particularly persistent pulmonary hypertension of the newborn, and does not address the gastrointestinal issues seen in NEC.

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Correct Answer is B

Explanation

Choice A rationale:

A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.

Choice B rationale:

Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.

Choice C rationale:

A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.

Choice D rationale:

Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.

A. The mother and the father are both Rh positive. B. The mother is Rh positive and the father is Rh negative. C. The mother is Rh negative and the father is Rh positive. D. The mother and the father are both Rh negative.

Correct Answer is C

Explanation

Choice A rationale:

If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

Choice B rationale:

When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.

Choice C rationale:

This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.

Choice D rationale:

If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

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Exhibits A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?