Exhibits

Here are the questions from the mix up well completed.

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

Perform a Nitrazine test.

Check client's temperature every hour.

Prepare the client for catheterization.

Ensure the client maintains a supine position while in bed.

Check FHR every 30 min.

Encourage frequent ambulation.

Obtain CBC blood sample.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation of Each Intervention

Perform a Nitrazine test ✅ This is appropriate to confirm rupture of membranes, especially since the client reports leaking fluid.
Check client's temperature every hour ✅ Frequent temperature monitoring is essential after suspected rupture of membranes to detect early signs of infection.
Prepare the client for catheterization 🟡 Not essential unless the client is unable to void or there's a medical indication. She has voided 50 mL, so no immediate need.
Ensure the client maintains a supine position while in bed ❌ Supine positioning can compress the vena cava and reduce placental perfusion. Left lateral or upright positions are preferred.
Check FHR every 30 min ✅ Appropriate for early labor with reassuring fetal heart rate and moderate variability.
Encourage frequent ambulation ✅ Promotes labor progression and comfort, especially with mild contractions and stable vitals.
Obtain CBC blood sample 🟡 May be useful if infection is suspected or labor progresses, but not immediately essential based on current data.

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Correct Answer is C

Explanation

Choice A rationale

Applying vitamin E oil to the nipples is not generally recommended; it offers little benefit and could potentially introduce unnecessary substances to the infant during feeding. Lanolin cream or purified lanolin is often recommended for sore nipples because it provides moisture, promotes healing by creating a barrier, and is safe for the baby to ingest. Proper latch technique is the primary intervention for preventing nipple soreness.

Choice B rationale

Limiting feeding time to 5 to 10 minutes per breast is incorrect and can lead to inadequate milk intake and insufficient stimulation for milk production. The infant should be allowed to feed for as long as they actively suckle and swallow, usually 15 to 20 minutes or until the breast feels softer, ensuring they receive the higher-calorie hindmilk.

Choice C rationale

Positioning the baby on a pillow at the level of the breast promotes a more comfortable and effective latch. Proper positioning allows the infant's mouth to be level with the nipple, ensuring the baby can take in a large portion of the areola and preventing strain on the mother's back, which facilitates a deeper and more comfortable latch for effective milk transfer.

Choice D rationale

Ensuring just the nipple is in the baby's mouth is an incorrect technique and is a common cause of nipple soreness and inadequate milk transfer. The baby needs to take in a large portion of the areola to effectively compress the milk sinuses underneath, achieving a deep latch that stimulates milk release and minimizes nipple trauma.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct answers: Transient hypoglycemia is common in the first hours of life, especially in macrosomic infants due to maternal hyperglycemia-induced fetal hyperinsulinemia. Blood glucose <40–45 mg/dL is abnormal; this newborn had 35 mg/dL initially, improved to 50 mg/dL after feeding. Symptoms like jitteriness, abnormal cry, and mild hypotonia resolved post-breastfeeding. Breastfeeding provides lactose, which is hydrolyzed to glucose and galactose, correcting hypoglycemia physiologically. Early feeding is first-line for asymptomatic or mildly symptomatic neonates with glucose >25 mg/dL.

Rationale for incorrect Response 1 options: Signs of infection (e.g., temperature instability, poor feeding, lethargy) may overlap with hypoglycemia but require systemic signs and lab confirmation. This newborn improved with feeding and had no fever, tachypnea, or leukocytosis. Respiratory distress presents with grunting, nasal flaring, retractions, and desaturation. The newborn’s respiratory rate was normal (45/min), no distress signs noted. Hyperbilirubinemia manifests as jaundice, typically after 24 hours. No yellowing of skin or sclera was reported; phototherapy is not indicated.

Rationale for incorrect Response 2 options: Administer antibiotics is appropriate for suspected sepsis, not isolated hypoglycemia. No infectious signs or risk factors were present. Provide oxygen support is reserved for respiratory compromise. The newborn had stable vitals and no hypoxia. Initiate phototherapy treats elevated bilirubin. No bilirubin levels or jaundice signs were documented.

Take-home points:

Transient neonatal hypoglycemia is common in macrosomic infants due to hyperinsulinemia.
Early breastfeeding is the preferred intervention for mild hypoglycemia with stable vitals.
Differentiate hypoglycemia from sepsis and respiratory distress using targeted clinical signs.
Phototherapy is reserved for hyperbilirubinemia; not indicated without jaundice or elevated bilirubin.

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Exhibits Here are the questions from the mix up well completed. The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about breastfeeding with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?

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 is caring for a client who is 12 hours postpartum and has an episiotomy. Which of the following actions should the nurse take?

A nurse is assisting in the initiation of phototherapy. Which nursing action is indicated for the newborn?

A nurse is preparing to administer acyclovir 400 mg tablet PO three times per day. Available is 800 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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 is reinforcing teaching about the correct use of infant car seats with the parent of a newborn. Which of the following statements by the parent indicate an understanding of the teaching?

Exhibits A nurse is assisting in the care of a newborn. Which of the following should be included in the electronic medical record (EMR)? Select all that apply.

Exhibits

Here are the questions from the mix up well completed.

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?