Exhibit 1. Exhibit 2. Exhibit 3. Nurses' notes:. Decreased activity level over the last 12 hr. Abdominal distention. Three bloody stools over the last 4 hr. Superficial rash on the abdominal wall. Light palpation of the abdomen leads to fist clenching, thrashing, and crying. 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 B

Choice A rationale:

The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.

Choice D rationale:

Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale:

Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.

Choice B rationale:

Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.

Choice C rationale:

Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.

Choice D rationale:

Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.

A. Request that the provider insert an intrauterine pressure catheter. B. Exert continuous upward pressure on the presenting part. C. Initiate oxytocin via continuous IV infusion. D. Place the client in the left-lateral position.

Correct Answer is B

Explanation

Choice A rationale:

Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.

Choice B rationale:

Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.

Choice C rationale:

Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.

Choice D rationale:

Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

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?

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?