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A nurse is caring for a newborn 1 hr following birth.

Medical History 1000:

39- week gestation

Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min

Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.

Hemoglobin

Hematocrit

Heart rate

Serum glucose

White blood cells

Respiratory assessment

Answer and Explanation

Correct Answer : A,B,C,D,F

A, B Monitoring the newborn's hemoglobin and hematocrit levels are important due to the risk of anemia.

C. Monitoring the newborn's heart rate post-birth is crucial for assessing cardiac function and detecting any abnormalities.

F. Positive pressure ventilation was administered to the newborn for 1 minute after birth, indicating a need for respiratory support. The nurse should closely assess the newborn's respiratory status.

D. There may be concerns about the newborn's blood glucose levels, especially if there were any periods of hypoxia or stress during labor and delivery.

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Correct Answer is B

Explanation

One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.

A. Assess maternal blood glucose. B. Prepare for an emergency cesarean birth. C. Place the client in Trendelenburg position. D. Discontinue the medication infusion.

Correct Answer is D

Explanation

Rationale

The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular blockade. The nurse should stop the infusion immediately.

A Monitoring blood glucose is important, but not a priority.

B. Magnesium sulphate toxicity is not an indication for emergency delivery.

C. Placing the client in Trendelenburg position is not appropriate in this situation. trendelenburg position could worsen respiratory depression and compromise the client's airway.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is B

Explanation

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse receives a mother and baby in postpartum. The baby is approximately 2 hours old. During the assessment of the baby the nurse recognizes the following symptoms of transient tachypnea of the newborn except for-

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?