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

Adjust room temperature between 75°F and 80°F

Wear a disposable gown when giving infant care

Keep the newborn dressed warmly

Wash hands before touching each baby

Answer and Explanation

The Correct Answer is D

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.

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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.

A. Request the provider perform a vaginal examination. B. Check the client's fundus. C. Measure the client's vital signs. D. Feel for a full bladder.

Correct Answer is B

Explanation

Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.

Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.

Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.

Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is B

Explanation

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 is 12 hr postpartum. Which of the following findings should the nurse expect?

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?

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

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?

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:

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