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?

Physiologic jaundice

Pathologic jaundice

Breast milk jaundice

Answer and Explanation

The Correct Answer is B

Pathologic jaundice. This type of jaundice occurs within the first 24 hours of birth and is caused by an underlying health condition, such as blood type incompatibility, infection, or liver problems. It can lead to serious complications, such as brain damage, if not treated promptly. Pathologic jaundice requires medical attention and often involves phototherapy or blood transfusion to lower the bilirubin levels in the baby's blood.

Choice A is not correct because physiologic jaundice is a normal and harmless condition that affects most newborns. It usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.

Choice C is not correct because breast milk jaundice is a rare condition that affects some breastfed babies. It usually appears after the first week of life and lasts up to a month or longer. It is caused by a substance in breast milk that interferes with the liver's ability to eliminate bilirubin.

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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.

A. Gentle massage of the affected leg B. Anticoagulants for 6 weeks C. Passive leg exercises twice a day D. Application of ice to the affected leg

Correct Answer is B

Explanation

Anticoagulants for 6 weeks. This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.

Choice A is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.

Choice C is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.

Choice D is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:

Correct Answer is B

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?

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?

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

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:

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the body?

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

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

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