The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?

Establish IV access

Assess the client's vital signs

Obtain fetal heart rate

Perform a sterile vaginal exam

Answer and Explanation

The Correct Answer is C

A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.

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Correct Answer is B

Explanation

A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.

A. The newborn who has cyanotic hands and feet. B. The newborns whose head turns toward the cheek being stroked C. The newborn whose toes curl when the lateral heel is stroked D. The newborn who extends the arms when hearing a loud noise

Correct Answer is A

Explanation

A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.

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The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Correct Answer is B

Explanation

Which newborn assessment finding would require the nurse to report to the health care provider?

Correct Answer is A

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of her son's circumcision care? (Select All that Apply.)

A nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?

Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.

The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?

The following newborns are three-hours old and are sleeping. The registered nurse should notify the provider about which newborn?

The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)