The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective thermoregulation related to heat loss to the environment.

Altered nutrition less than body requirement related to limited formula intake.

Altered urinary elimination related to post-circumcision status.

Ineffective airway clearance related to mucus and water secretions.

Answer and Explanation

The Correct Answer is D

Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.

Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.

Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.

Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.

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Correct Answer is D

Explanation

Wash hands before touching each baby. This is because hand hygiene is the most effective way to prevent infection transmission in the nursery. Hand hygiene should be performed before and after every patient contact, as well as before and after wearing gloves or handling equipment. Hand hygiene can be done by washing hands with soap and water or using alcohol-based hand rubs.

Choice A is not correct because adjusting room temperature between 75°F and 80°F is not a measure to protect newborns from infection. The room temperature should be maintained within a comfortable range for newborns, but it does not affect infection risk.

Choice B is not correct because wearing a disposable gown when giving infant care is not a measure to protect newborns from infection. Disposable gowns are part of contact precautions, which are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. They are not necessary for routine infant care.

Choice C is not correct because keeping the newborn dressed warmly is not a measure to protect newborns from infection. Keeping the newborn dressed warmly can help prevent heat loss and hypothermia, but it does not affect infection risk.

A. Thromboembolism B. Cervical laceration C. Hemorrhoids D. Hemorrhage

Correct Answer is D

Explanation

Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.

Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.

Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.

Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.

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The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To protect newborns from infection while in the nursery, the nurse plans to:

Correct Answer is D

Explanation

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

Correct Answer is D

Explanation

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

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?

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

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

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.