Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Newborn has had 4 transitional stools during the shift

Urine output remains unchanged with a dark yellow appearance

Lungs clear, no retractions noted

Edematous area on right scalp softening, ecchymosis present

Total serum bilirubin 14.2 mg/dL

Facial bruising present with yellow discoloration of the face

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Transitional stools indicate progression from meconium to normal infant stool, reflecting adequate feeding and gastrointestinal function. These stools are typically greenish-brown to yellow and appear within the first few days of life. Four stools in one shift suggest active peristalsis and effective bilirubin excretion via feces. This is a positive sign in managing hyperbilirubinemia, as bilirubin is eliminated through the gastrointestinal tract, supporting clinical improvement.

Choice B rationale: Dark yellow urine may suggest concentrated output, potentially indicating suboptimal hydration. While unchanged output may seem stable, the color implies reduced fluid intake or increased bilirubin excretion. In neonates, urine should be pale yellow if hydration is adequate. Persistent dark urine warrants follow-up to assess feeding adequacy and renal function. It is not a definitive sign of expected progression and may signal a need for increased fluid intake.

Choice C rationale: Clear lungs and absence of retractions indicate effective respiratory function and no signs of distress. Retractions are a compensatory mechanism for increased work of breathing, often seen in respiratory compromise. Their absence, along with clear auscultation, suggests normal pulmonary transition and oxygenation. This finding confirms that the newborn is adapting well postnatally, with stable respiratory status and no need for supplemental oxygen or intervention.

Choice D rationale: Softening of the edematous scalp area and presence of ecchymosis suggest resolution of birth trauma, likely a cephalohematoma from vacuum extraction. As blood reabsorbs, firmness decreases and bruising becomes more apparent. This progression is expected and indicates healing. Monitoring is still required for bilirubin levels due to hemolysis, but the physical changes reflect normal recovery from localized trauma without signs of infection or worsening.

Choice E rationale: A total serum bilirubin level of 14.2 mg/dL remains above the normal range (1 to 12 mg/dL) and indicates ongoing hyperbilirubinemia. Although it has decreased from the previous day’s 18.5 mg/dL, it still exceeds the threshold for concern. Continued phototherapy and monitoring are necessary. This value does not yet reflect full resolution, so it cannot be considered a sign of expected progression without further decline.

Choice F rationale: Facial bruising with yellow discoloration suggests ongoing breakdown of red blood cells and bilirubin deposition in the skin. While bruising may resolve over time, the yellowing indicates persistent jaundice. This is a sign of elevated bilirubin and not a marker of improvement. It requires continued phototherapy and monitoring. Therefore, it does not indicate expected progression and warrants follow-up.

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Correct Answer is A

Explanation

Choice A rationale

Applying witch hazel compresses (such as Tucks pads) is an effective and preferred action for postpartum perineal discomfort, including episiotomy pain. Witch hazel contains tannins and volatile oils that provide an astringent and anti-inflammatory effect. This action helps to reduce swelling, soothe the tissues, and offer immediate, localized pain relief at the episiotomy site.

Choice B rationale

Administering aspirin (acetylsalicylic acid) for postpartum discomfort is generally contraindicated. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which could increase the risk of bleeding postpartum, especially from the placental insertion site or the episiotomy wound. Preferred analgesics are typically acetaminophen or ibuprofen, which have less impact on coagulation.

Choice C rationale

Having the client use a warm pack is not the initial treatment for episiotomy pain within the first 24 hours. Heat promotes vasodilation, which can increase edema and pain in the acutely inflamed and traumatized tissues. Cold therapy (e.g., ice packs) is the standard initial treatment because it causes vasoconstriction, which minimizes swelling and provides a local anesthetic effect.

Choice D rationale

Instructing the client to sit on a soft pillow might seem helpful, but it can sometimes be detrimental. Sitting on a soft, ring-shaped, or inflated pillow can cause the client to press outward on the soft tissues of the perineum, potentially increasing pressure and discomfort on the episiotomy incision. Sitting on a firm surface with the buttocks shifted can be more comfortable for some.

A. Avoid urinating at bedtime. B. Wear cotton-crotch underwear. C. Eliminate yogurt products from the diet. D. Douche after each sexual encounter. E. Refrain from taking bubble baths.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

The instruction to avoid urinating at bedtime is incorrect and potentially harmful. Urinary stasis (urine sitting in the bladder) is a major risk factor for bacterial growth and recurrence of a urinary tract infection (UTI). Complete and frequent bladder emptying, including right before bed, is essential to flush out potential pathogens and prevent the ascent of bacteria, thereby minimizing the opportunity for bacterial proliferation within the urinary tract.

Choice B rationale

Wearing cotton-crotch underwear is recommended because cotton is highly breathable and absorbent, promoting air circulation and minimizing moisture retention in the perineal area. A dry environment inhibits the growth of bacteria and yeast, which can ascend into the urethra, potentially leading to a recurrent urinary tract infection (UTI). Synthetic fabrics trap heat and moisture, creating a more favorable medium for pathogen proliferation.

Choice C rationale

The instruction to eliminate yogurt products from the diet is incorrect. Yogurt containing live and active cultures (probiotics, such as Lactobacillus) can actually be beneficial. These beneficial bacteria may help maintain the normal balance of flora, especially in the vagina and surrounding area, which can inhibit the overgrowth of pathogenic bacteria (E. coli) that commonly cause urinary tract infections.

Choice D rationale

Douching is generally discouraged as it can disrupt the normal vaginal flora (primarily Lactobacillus), altering the protective acidic pH (normal 3.5-4.5). This disruption can increase the risk of both vaginal infections and ascending infections that may lead to a recurrent urinary tract infection (UTI). The vagina is a self-cleaning organ, and douching can inadvertently push bacteria higher into the reproductive or urinary tracts.

Choice E rationale

Refraining from taking bubble baths is a correct instruction. Soaps, detergents, and chemicals in bubble baths can cause irritation to the urethral meatus and surrounding tissues. This irritation makes the area more susceptible to colonization by bacteria, such as those from the perianal region, which can then ascend the urethra and lead to the development or recurrence of a urinary tract infection (UTI).

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Exhibits Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 10 hours postpartum following a vaginal delivery and reports discomfort at the episiotomy site. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who is pregnant and was treated for a urinary tract infection. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is collecting data from a newborn who is 4 hours old. Which of the following findings should the nurse report to the provider?

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Exhibits Question 2(B) Complete the following sentence by using the lists of options. The nurse should first dropdownbefore performing a heel stick, followed bydropdown.

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Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.