Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
What is the priority action for a nurse when a newborn has a respiratory rate of 72 breaths per
minute with grunting?
✔✔ Notify the provider immediately
What is the most likely cause of a soft, boggy uterus above the umbilicus in a postpartum client?
✔✔ Uterine atony
How many wet diapers per day indicates adequate hydration in a newborn after day four?
✔✔ At least six
What is the first action a nurse should take when a mother reports heavy vaginal bleeding after
delivery?
✔✔ Massage the fundus
What is the most appropriate way to relieve breast engorgement in a non-breastfeeding client?
1
,✔✔ Apply cold compresses to the breasts
Which position should the nurse place a pregnant client in to relieve supine hypotension?
✔✔ Left lateral position
What is the recommended time to initiate the first breastfeeding session after birth?
✔✔ Within the first hour of life
What does a positive Coombs test in a newborn indicate?
✔✔ Presence of maternal antibodies against newborn's red blood cells
What finding in a newborn suggests hypoglycemia?
✔✔ Jitteriness
What should the nurse assess for first after the rupture of membranes during labor?
✔✔ Fetal heart rate
What is the expected fundal location on the first postpartum day?
2
,✔✔ One fingerbreadth below the umbilicus
What is the best way to prevent newborn heat loss by evaporation?
✔✔ Dry the newborn immediately after birth
What reflex is demonstrated when the newborn fans toes after stroking the sole of the foot?
✔✔ Babinski reflex
What vitamin is administered to a newborn to promote blood clotting?
✔✔ Vitamin K
What is the term for the first milk produced that is rich in antibodies?
✔✔ Colostrum
What is the normal temperature range for a healthy newborn in Celsius?
✔✔ 36.5°C to 37.5°C
Which assessment finding is expected in a newborn with caput succedaneum?
3
, ✔✔ Soft swelling that crosses suture lines
What is the term for a bluish discoloration of a newborn's hands and feet?
✔✔ Acrocyanosis
What should a nurse do if a postpartum client complains of pain and warmth in one leg?
✔✔ Notify the provider due to risk of thrombophlebitis
What should a nurse encourage for a postpartum client experiencing constipation?
✔✔ Increase fluid and fiber intake
What is the purpose of performing Leopold’s maneuvers during pregnancy?
✔✔ To determine fetal position
What finding would require immediate attention in a newborn?
✔✔ Central cyanosis
What is the expected weight loss percentage for a healthy newborn in the first few days of life?
4