You are assessing the baby and notice that their hands and feet are bluish-purple. You:

Don't do anything, this is a normal finding

Check the infant's 02 sat

Call the MD for referral

Put socks and mittens on the infant to keep them warm

Answer and Explanation

The Correct Answer is B

A) Don't do anything, this is a normal finding:
While it's true that acrocyanosis (bluish-purple discoloration of the hands and feet) can be a normal finding in the first 24-48 hours of life due to immature circulation, it’s important to assess the severity of the condition and rule out more serious causes. Just ignoring it without assessing the infant’s oxygenation status could lead to missing a potential respiratory issue.

B) Check the infant's O2 sat:
The most appropriate action is to assess the infant’s oxygen saturation levels. Acrocyanosis is typically benign and resolves on its own, but persistent cyanosis or a drop in oxygen saturation could indicate a more serious issue, such as respiratory distress or congenital heart disease. A pulse oximeter is a non-invasive tool that can help determine whether the infant’s oxygenation is adequate. This would help guide further clinical decisions.
C) Call the MD for referral:
Calling the doctor should only be considered if the baby’s oxygen saturation levels are low, or if other concerning symptoms (like poor feeding, lethargy, or significant difficulty breathing) are present. If the O2 saturation is normal, there’s no immediate need for referral. The key is to assess first before escalating to the provider.

D) Put socks and mittens on the infant to keep them warm:
Although providing warmth can help with maintaining body temperature, simply putting socks and mittens on the baby is not sufficient to rule out respiratory issues or other causes of cyanosis. If the infant’s oxygen saturation is normal and the baby is otherwise stable, this may be appropriate. However, checking the O2 saturation first is the correct step to ensure that no underlying respiratory problems are contributing to the cyanosis.

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Correct Answer is A

Explanation

A) Assess the woman's fundus and massage it if boggy:
A saturated pad within 15 minutes after delivery suggests a hemorrhage, and the first priority in this situation is to assess the fundus. If the fundus is boggy (soft and not contracted), it is a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contraction, which can help stop the bleeding.

B) Assess the woman's pulse and BP for signs of hypovolemic shock:
While it is important to monitor vital signs for signs of hypovolemic shock (e.g., increased heart rate, decreased blood pressure, and pale skin), this action would not be the first priority in managing a postpartum hemorrhage. The immediate focus should be on stopping the bleeding by addressing uterine atony. Hypovolemic shock assessment is important, but it comes after the initial steps of managing hemorrhage.

C) Call the woman's primary healthcare provider:
Calling the provider may be necessary if the bleeding does not stop after initial interventions. However, it should not be the first action. The nurse should first assess the uterus and attempt to stop the bleeding by massaging the fundus before calling the provider.

D) Begin an IV infusion of Ringer's lactate solution and administer oxytocin:
Starting an IV infusion and administering oxytocin may be part of the treatment for postpartum hemorrhage, but the first action should be to assess and manage the fundus. Oxytocin can help contract the uterus, but massaging the fundus is the immediate intervention. Intravenous fluids and medications should be initiated once the uterus is assessed and massaged, especially if bleeding persists.

A. The fundus is palpable two fingerbreadths above the umbilicus. B. The fundus is palpable at the level of the umbilicus. C. The fundus is palpable one fingerbreadth below the umbilicus. D. The fundus is palpable two fingerbreadths below the umbilicus.

Correct Answer is D

Explanation

A. The fundus is palpable two fingerbreadths above the umbilicus:
While it is higher than expected, this finding may occur if the uterus is still contracting and involuting, as it can sometimes be positioned slightly higher. However, this is not necessarily a cause for concern, and further assessment would depend on other factors like bleeding or discomfort. If the fundus is firm and contractions are present, this finding may still be within a normal range.

B. The fundus is palpable at the level of the umbilicus:
At 12 hours postpartum, the fundus should generally be at the level of the umbilicus. This is an expected finding in the immediate postpartum period as the uterus is beginning to involute. No further action is required unless other complications, like excessive bleeding or signs of infection, are present.

C. The fundus is palpable one fingerbreadth below the umbilicus:
This is another typical finding 12 hours after birth. By this time, the uterus should be involuting and should be slightly below the umbilicus. A slight descent of the fundus is normal as the uterus shrinks and contracts. As long as the fundus is firm and there are no other concerning signs, this is a normal finding.

D. The fundus is palpable two fingerbreadths below the umbilicus:
A fundus palpated two fingerbreadths below the umbilicus 12 hours postpartum suggests that involution may not be progressing as expected. It could indicate uterine atony, where the uterus is not contracting effectively, increasing the risk for postpartum hemorrhage. This requires further assessment to rule out complications such as retained placental fragments or excessive bleeding. Immediate action, including uterine massage or other interventions, may be needed.

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You are assessing the baby and notice that their hands and feet are bluish-purple. You:

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Naxlex Comprehensive Predictor Exams

While assessing a patient who gave birth 5 hours ago, the nurse finds that the woman has completely saturated: pad within 15 minutes. What is the nurse's first action?

Correct Answer is A

Explanation

Which finding 12 hours after birth requires further assessment?

Correct Answer is D

Explanation

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