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The nurse is assessing a newborn who has just been admitted to the nursery.

The nurse is assessing a newborn who has just been admitted to the nursery. Which of the following findings requires further assessment by the nurse?

a. An edematous area on the occiput of the scalp.

b. Head is 1/4 the total body length.

c. Transient rash with macules and papules.

d. Irregular shape of blue-grey pigmentation over the sacral area.

 
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The nurse is observing a new mother care for her newborn for the first time.

The nurse is observing a new mother care for her newborn for the first time. Which of the following observations requires the nurse to intervene?

a. Mother heating a bottle of formula in a pan of water.

b. Mother supporting the head when holding the newborn.

c. Mother keeping the diaper below the umbilical cord.

d. Mother cleaning the newborn’s eyes from outer to inner canthus.

 
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The nurse is caring for a newborn immediately following birth.

The nurse is caring for a newborn immediately following birth. After ensuring a patent airway, which of the following is the priority nursing action?

a. Dry the skin.

b. Administer eye prophylaxis

c. Administer vitamin K.

d. Place an identification bracelet.

 
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The nurse is observing a new mother care for her newborn for the first time.

The nurse is observing a new mother care for her newborn for the first time. Which of the following observations requires the nurse to intervene?

a. Mother heating a bottle of formula in a pan of water.

b. Mother supporting the head when holding the newborn.

c. Mother keeping the diaper below the umbilical cord.

d. Mother cleaning the newborn’s eyes from outer to inner canthus.

 
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The nurse is working in the nursery caring for assigned newborns.

The nurse is working in the nursery caring for assigned newborns. Which of the following newborn assessments should the nurse consider to be abnormal?

a. Newborn who is 12 hours post-delivery and has a Mongolian spot.

b. Newborn who is 16 hours post-delivery and has not passed meconium.

c. Newborn who is 2 hours post-delivery and has webbing of digits.

d. Newborn who is 18 hours post-delivery and has acrocyanosis.

 
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The nurse is assessing newborn. Which of following findings is apriority for the nurse to follow-up?

The nurse is assessing newborn. Which of following findings is apriority for the nurse to follow-up?

a. Chin quivering and a positive gag reflex.

b. Erythema toxicum and milia.

c. Respirations of 50 and temperature of 990 F.

d. Blood pressure of 55/40 mm Hg and a pulse of 95.

 
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The nurse is caring for the following newborn clients. Which client should the nurse assess first?

The nurse is caring for the following newborn clients. Which client should the nurse assess first?

a. The newborn who is 10 hours old and has periods of apnea lasting 5 seconds.

b. The newborn who is 18 hours old and has not passed a meconium stool.

c. The newborn who is 4 hours old and has a low temperature.

d. The newborn who is 12 hours old and has blue hands and feet.

 
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The nurse is preparing to assess a postpartum client’s boggy fundus.

The nurse is preparing to assess a postpartum client’s boggy fundus. Which of the following should the nurse ask the client prior to palpation?

a. Ask the client if they have used the restroom recently.

b. Ask the client to raise the bed to 60 degrees.

c. Ask the client to attempt a bowel movement.

d. Ask the client to place the hands under the head.

 
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The nurse is caring for a client who delivered vaginally 2 hours ago.

The nurse is caring for a client who delivered vaginally 2 hours ago. The fundus is right of midline and firm only with massage. Which of the following actions is the priority for the nurse?

a. Assist the client to the restroom.

b. Obtain a urinary specimen for analysis.

c. Insert an indwelling urethral catheter.

d. Perform a straight catheterization.

 
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