The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Gastroesophageal reflux

Sudden infant death syndrome

Apnea episodes

Sleeping for short intervals

Answer and Explanation

The Correct Answer is B

Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating .

Choice A is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.

Choice C is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.

Choice D is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.

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Correct Answer is B

Explanation

Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks. Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.

Choice A is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.

Choice C is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal.

Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.

Choice D is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.

A. Blood pressure B. Amount of lochia C. Fulness of the bladder D. Level of pain

Correct Answer is C

Explanation

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

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The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Correct Answer is B

Explanation

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Correct Answer is C

Explanation

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

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

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

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?

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

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:

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be: