The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

Document expected postpartum mucous membrane congestion

Notify the charge nurse of a possible upper respiratory infection

Notify the physician of a possible pulmonary embolism

Medicate with antipyretic remedy for elevated temperature

Answer and Explanation

The Correct Answer is C

Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.

Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.

Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.

Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.

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Correct Answer is C

Explanation

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

A. Monitor the newborn's blood glucose level hourly. B. Apply lotion to the newborn's skin twice per day. C. Encourage the newborn to breastfeed every 2 hr. D. Maintain the newborn in a prone position.

Correct Answer is C

Explanation

Encourage the newborn to breastfeed every 2 hr. This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.

Choice A is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.

Choice B is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.

Choice D is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.

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The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

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Naxlex Comprehensive Predictor Exams

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Correct Answer is C

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any: