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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is []

Explanation

Rationale for correct condition Endometritis is a postpartum uterine infection, common after cesarean birth and prolonged rupture of membranes. The client presents with fever >38°C, uterine tenderness, and foul-smelling lochia, hallmark signs of endometritis. A boggy uterus indicates subinvolution due to infection. Malaise and chills reflect systemic inflammatory response. Bottle-feeding excludes mastitis or engorgement as primary cause.

Rationale for correct actions Broad-spectrum antibiotics like clindamycin and gentamicin target polymicrobial flora including group B streptococci and anaerobes. Prompt administration reduces risk of sepsis and uterine abscess. Oxytocic agents like oxytocin promote uterine contraction, aiding involution and expulsion of infected lochia. This reduces bacterial load and improves antibiotic penetration.

Rationale for correct parameters Temperature monitoring detects systemic infection progression; normal postpartum range is <38°C. Persistent elevation suggests inadequate response to therapy. Lochia assessment identifies changes in volume and odor; normal lochia rubra transitions to serosa by day 3–4. Foul odor and dark color indicate retained infected tissue.

Rationale for incorrect conditions Deep vein thrombosis presents with unilateral leg pain, warmth, and swelling, absent here. Urinary tract infection causes dysuria, urgency, and suprapubic pain, not present. Engorgement causes bilateral breast fullness and discomfort, but client is bottle-feeding and denies nipple pain.

Rationale for incorrect actions Anticoagulant therapy is irrelevant without thrombotic signs. Fluid intake helps urinary tract infections, not uterine infections. Ice packs treat breast engorgement, not uterine infection.

Rationale for incorrect parameters Nipple integrity relates to breastfeeding complications. Bladder distention is not present and unrelated to uterine infection. Leg circumference monitors DVT, not endometritis.

Take home points:

Endometritis is a postpartum uterine infection marked by fever, uterine tenderness, and foul lochia.
Cesarean delivery and prolonged rupture of membranes are major risk factors.
Management includes antibiotics and uterine contraction support.
Differentiate from DVT, UTI, and engorgement using targeted signs and history.

A. Apply oxygen by face mask. B. Weigh the perineal pad. C. Perform fundal massage. D. Monitor urine output.

Correct Answer is C

Explanation

Choice A rationale

. Applying oxygen is a supportive measure for the client experiencing significant blood loss and circulatory compromise, but it is not the highest priority action to stop the hemorrhage. The physiological basis for applying oxygen is to maximize the oxygen content of the circulating blood, addressing tissue hypoxia secondary to hypovolemic shock.

Choice B rationale

. Weighing the perineal pad is a necessary step to accurately quantify blood loss (1 gram of weight equals approximately 1 milliliter of blood) for accurate diagnosis of postpartum hemorrhage (PPH) and to guide treatment. However, it is an assessment and documentation action, not the most critical intervention to immediately address the source of the bleeding.

Choice C rationale

. Performing a fundal massage is the highest priority and most critical intervention when a client reports rapid and heavy postpartum bleeding, which suggests uterine atony (a soft, boggy uterus). Uterine atony is the most common cause of early postpartum hemorrhage, and manual stimulation immediately causes the uterine muscle fibers to contract, which constricts the blood vessels and rapidly reduces blood loss.

Choice D rationale

. Monitoring urine output is an important assessment of renal perfusion and fluid status, which is essential to track the progression of potential hypovolemic shock due to hemorrhage. A urine output of less than 30 mL/hour suggests inadequate renal perfusion. However, this is an assessment and a later indicator of the severity of shock, not the immediate, life-saving intervention needed to halt the bleeding source.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is []

Explanation

A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes. Which of the following actions is the highest priority?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is reinforcing teaching with a group of women about the use of acupressure to relieve discomfort during labor. Which of the following instructions should the nurse include in the teaching?

A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Select the 5 actions the nurse should take next.

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?

A nurse is reinforcing teaching at a prenatal visit about the importance of adequate folic acid intake with a client who is at 12 weeks of gestation. Which of the following client statements indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron. Which of the following foods should the nurse recommend as the best source of iron?

A nurse is reinforcing teaching about home safety precautions with the guardian of a newborn. Which of the following instructions should the nurse include?

Exhibits A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting dropdownthe nurse should plan todropdown.

The nurse reinforces teaching regarding newborn hypoglycemia. Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.

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.