Which action is most important for the nurse to implement?

Increase IV infusion rate.

Assess the vital signs.

Massage the fundus.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.

Choice B rationale

Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.

Choice C rationale

Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.

Choice D rationale

Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.

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Correct Answer is C

Explanation

Choice A rationale

Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.

Choice B rationale

A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.

Choice C rationale

A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.

Choice D rationale

While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.

A. Seizures. B. Stroke. C. Organ damage. D. Preterm birth.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Seizures can occur due to severe preeclampsia, leading to eclampsia, characterized by generalized tonic-clonic seizures. Magnesium sulfate is often used to prevent seizures in these patients, alongside other monitoring measures.

Choice B rationale

Stroke risk is elevated in preeclamptic patients due to hypertension, endothelial dysfunction, and increased coagulation. Blood pressure control is essential to reduce stroke risk and manage preeclampsia complications effectively.

Choice C rationale

Organ damage, particularly to the liver and kidneys, is a complication of preeclampsia. Elevated liver enzymes and proteinuria indicate hepatic and renal involvement, necessitating close monitoring and potential intervention to mitigate damage.

Choice D rationale

Preterm birth is often a result of preeclampsia due to placental insufficiency and maternal health deterioration. Early delivery may be necessary to protect the well-being of both mother and fetus, highlighting the importance of timely diagnosis.

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Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

Correct Answer is ["A","B","C","D"]

Explanation

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Which action is most important for the nurse to implement?

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