A nurse is caring for a newborn.
8 hr of age:
Temp: 37.1 C(98.8 F) Axillary
Pulse rate: 132/min
Resp rate: 52/min
36 hr of age:
Temp: 36.1 C (97 F) Axillary
Pulse rate: 160/min
Resp rate: 78/min
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
Each finding may support more than one disease process.
Poor feeding: Hypoglycemia, Hyperbilirubinemia, Sepsis
Lethargy: Hypoglycemia, Sepsis
Yellow sclera and oral mucosa: Hyperbilirubinemia, Sepsis
Decreased temperature: Hypoglycemia, Sepsis
Respiratory distress: Hypoglycemia, Sepsis
Ecchymotic caput succedaneum: Hyperbilirubinemia
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an
indication that the newborn is experiencing pain?
a. decreased heart rate
b. chin quivering
c. pinpoint pupils
d. slowed respirations
b. Chin quivering
,A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following
statements by the client indicates an understanding of the teaching?
a. "I should increase my protein intake to 60 g each day."
b. "I should drink 2 liters of water each day"
c. "I should increase my overall daily caloric intake by 300 calories each day."
d. "I should take 600 micrograms of folic acid each day."
d. "I should take 600 micrograms of folic acid each day."
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse
include in the plan of care?
a. Maintain the client NPO throughout the procedure.
b. Place the client in a supine position.
c. Instruct the client to massage the abdomen to stimulate fetal movement.
d. Instruct the client to press the provided button each time fetal movement is detected.
d. Instruct the client to press the provided button each time fetal movement is detected
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should
the nurse take?
a. Ensure the parent's identification band number matches the newborn's identification band number
b. Ask the parent's to verify their name and date of birth.
c. Check the newborn's security tag number to ensure it matches the newborn's medical record
d. Match the newborn's date and time of birth to the information in the parent's medical record.
a. Ensure the parent's identification band number matches the newborn's identification band number
, A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings
contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
a. Late decelerations
b. Moderate variability of the FHR
c. Cessation of uterine dilation
d. Prolonged active phase of labor
a. Late decelerations
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks gestation. Which of the following
conditions is an indication for fetal assessment using electronic fetal monitoring?
a. Oligohydramnios
b. Hyperemesis gravidarum
c. Leukorrhea
d. Periodic tingling of fingers
a. Oligohydramnios
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the
following diagnostic tests should the nurse prepare the client?
a. Percutaneous umbilical blood sampling
b. Amnioinfusion
c. Biophysical profile (BPP)
d. Chorionic villus sampling (CVS)
c. Biophysical profile (BPP)
8 hr of age:
Temp: 37.1 C(98.8 F) Axillary
Pulse rate: 132/min
Resp rate: 52/min
36 hr of age:
Temp: 36.1 C (97 F) Axillary
Pulse rate: 160/min
Resp rate: 78/min
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
Each finding may support more than one disease process.
Poor feeding: Hypoglycemia, Hyperbilirubinemia, Sepsis
Lethargy: Hypoglycemia, Sepsis
Yellow sclera and oral mucosa: Hyperbilirubinemia, Sepsis
Decreased temperature: Hypoglycemia, Sepsis
Respiratory distress: Hypoglycemia, Sepsis
Ecchymotic caput succedaneum: Hyperbilirubinemia
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an
indication that the newborn is experiencing pain?
a. decreased heart rate
b. chin quivering
c. pinpoint pupils
d. slowed respirations
b. Chin quivering
,A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following
statements by the client indicates an understanding of the teaching?
a. "I should increase my protein intake to 60 g each day."
b. "I should drink 2 liters of water each day"
c. "I should increase my overall daily caloric intake by 300 calories each day."
d. "I should take 600 micrograms of folic acid each day."
d. "I should take 600 micrograms of folic acid each day."
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse
include in the plan of care?
a. Maintain the client NPO throughout the procedure.
b. Place the client in a supine position.
c. Instruct the client to massage the abdomen to stimulate fetal movement.
d. Instruct the client to press the provided button each time fetal movement is detected.
d. Instruct the client to press the provided button each time fetal movement is detected
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should
the nurse take?
a. Ensure the parent's identification band number matches the newborn's identification band number
b. Ask the parent's to verify their name and date of birth.
c. Check the newborn's security tag number to ensure it matches the newborn's medical record
d. Match the newborn's date and time of birth to the information in the parent's medical record.
a. Ensure the parent's identification band number matches the newborn's identification band number
, A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings
contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
a. Late decelerations
b. Moderate variability of the FHR
c. Cessation of uterine dilation
d. Prolonged active phase of labor
a. Late decelerations
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks gestation. Which of the following
conditions is an indication for fetal assessment using electronic fetal monitoring?
a. Oligohydramnios
b. Hyperemesis gravidarum
c. Leukorrhea
d. Periodic tingling of fingers
a. Oligohydramnios
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the
following diagnostic tests should the nurse prepare the client?
a. Percutaneous umbilical blood sampling
b. Amnioinfusion
c. Biophysical profile (BPP)
d. Chorionic villus sampling (CVS)
c. Biophysical profile (BPP)
