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 C

Explanation

Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.

Choice A. Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.

Choice B. Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.

Choice D. Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.

A. Place the client on seizure precautions. B. Cover the client with warm blankets. C. Notify the charge nurse. D. Determine the client's temperature.

Correct Answer is D

Explanation

Determine the client’s temperature. This is because shaking chills during the immediate postpartum period can be a sign of infection, such as endometritis or mastitis. Infection is a serious complication that can lead to sepsis and shock if not treated promptly. The nurse should measure the client’s temperature and look for other signs of infection, such as foul-smelling lochia, breast tenderness, or tachycardia.

Choice A is wrong because placing the client on seizure precautions is not indicated for shaking chills. Seizure precautions are used for clients who have eclampsia or other conditions that increase the risk of seizures.

Choice B is wrong because covering the client with warm blankets may not be helpful for shaking chills. Warm blankets may increase the body temperature and worsen the infection.

Choice C is wrong because notifying the charge nurse is not the first action the nurse should take. The nurse should assess the client’s condition before reporting to the charge nurse or the provider.

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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

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

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

Correct Answer is D

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:

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

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?

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

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:

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?