Question

What is the priority nursing intervention for an infant demonstrating respiratory distress after-delivery?

Answer 1

Correct Answers:

Perform suctioning to clear the airway and ensure patency.

Rationale :

💠 The priority nursing intervention in a newborn with respiratory distress is to establish and maintain a patent airway.

💠 Newborns commonly retain mucus, amniotic fluid, or secretions after delivery that can obstruct airflow.

💠 Suctioning the mouth first, then the nose helps improve oxygenation and ventilation.

💠 Adequate airway clearance supports effective breathing and gas exchange, which is critical immediately after birth.

💠 Airway management follows the ABCs (Airway, Breathing, Circulation), making this the first and most urgent action.

Encourage the parents to hold the infant for skin-to-skin contact

💠 Skin-to-skin promotes thermoregulation and bonding.

💠 It does not address acute respiratory compromise.

Swaddle the infant to maintain body temperature

💠 Swaddling helps prevent heat loss.

💠 Temperature management is important but secondary to airway and breathing.

Administer antibiotics to prevent infection

💠 Antibiotics are not given without evidence of infection.

💠 This action does not resolve immediate respiratory distress.

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Answer 2

Correct Answers

Blank 1 Correct Option: Postpartum Depression
Blank 2 Correct Option: Assess client for suicidal or homicidal ideation and Educate postpartum parent on need to follow-up care with a mental health professional
Blank 3 Correct Option: Signs of neglect of the infant and Worsening of depressive symptoms of postpartum parent.

Rationale :

💠 The postpartum parent demonstrates persistent sadness, tearfulness, and withdrawal beyond the expected timeframe for postpartum blues.

💠 The symptoms have continued for several weeks, exceeding the typical 2-week resolution of postpartum blues.

💠 The parent shows impaired bonding, minimal engagement, and avoidance of infant care.

💠 Functional impairment is evident as the grandparent performs most infant care.

💠 These findings align with postpartum depression, not anxiety, psychosis, or transient blues.

Assess client for suicidal or homicidal ideation.

💠 Postpartum depression carries a risk for self-harm or harm to others.

💠 Early assessment supports immediate safety planning if risk is identified.

Educate postpartum parent on need to follow-up care with a mental health professional.

💠 Postpartum depression requires professional evaluation and treatment.

💠 Referral supports therapy, medication if indicated, and recovery.

Signs of neglect of the infant.

💠 Ongoing disengagement can compromise infant safety and development.

💠 Monitoring ensures early detection of care deficits.

Worsening of depressive symptoms of postpartum parent.

💠 Tracking symptom severity helps evaluate treatment effectiveness.

💠 Worsening symptoms may require urgent intervention.

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Answer 3

Correct Answers:

Newborn who has not voided in 24 hours.

Rationale :

💠 Newborns should void within the first 24 hours of life, making absence of urination a red flag.

💠 Failure to void may indicate urinary tract obstruction, renal dysfunction, or dehydration.

💠 Early identification is critical to prevent electrolyte imbalance and kidney injury.

💠 This finding requires immediate evaluation and provider notification.

💠 Delayed voiding is more concerning than common, self-limiting newborn conditions.

Newborn who has erythema toxicum on torso

💠 Erythema toxicum is a benign, common newborn rash.

💠 It resolves spontaneously and does not require treatment.

Small, retractable protrusion next to the umbilicus

💠 This describes an umbilical hernia, which is common and usually resolves on its own.

💠 It is not an urgent finding unless nonreducible or strangulated.

Meconium passage with every bowel movement

💠 Passage of meconium is normal in the first days of life.

💠 Frequent meconium stools are expected and not concerning initially.

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Answer 4

Correct Answers:

"l need to have three shots to get my rubella levels up."

Rationale :

💠 Rubella immunization is provided as a single dose of the MMR vaccine, not a series of three injections.

💠 Postpartum clients who are nonimmune are vaccinated once to provide future protection.

💠 There is no routine recommendation for multiple doses unless immunity is not achieved on follow-up testing.

💠 This statement reflects misunderstanding of the vaccination schedule.

💠 Identifying this misconception signals the need for additional client teaching.

“I will get my rubella immunization before I leave the hospital.”

💠 Nonimmune postpartum clients should receive the MMR vaccine prior to discharge.

💠 This is appropriate because the vaccine is contraindicated during pregnancy, not postpartum.

“I may need to have a revaccination if I remain nonimmune.”

💠 Follow-up testing may show persistent nonimmunity in some clients.

💠 Revaccination may be recommended in that situation.

“Rubella is a bad disease that I need to be immunized against.”

💠 Rubella can cause serious congenital defects if contracted during pregnancy.

💠 Understanding the importance of immunization reflects accurate knowledge.

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Answer 5

Correct Answers:

Lungs and liver

Rationale :

💠 During fetal life, the lungs are nonfunctional because oxygenation occurs via the placenta, not through breathing.

💠 Fetal lungs are filled with fluid and bypassed by fetal circulation shunts (ductus arteriosus, foramen ovale).

💠 The liver is partially nonfunctional, as many metabolic and detoxification roles are handled by the placenta.

💠 After birth, clamping of the umbilical cord and the first breaths trigger activation of lung and liver function.

💠 Identifying lungs and liver reflects correct understanding of physiologic adaptations to extrauterine life.

Gastrointestinal system

💠 The GI system is functionally developed and capable of digestion after birth.

💠 It is not considered nonfunctional during fetal life.

Eyes and ears

💠 Sensory organs develop and are functional before birth.

💠 Newborns can see, hear, and respond to stimuli shortly after delivery.

Kidneys and liver

💠 Fetal kidneys do produce urine, contributing to amniotic fluid.

💠 The liver, while partially immature, is not completely nonfunctional.

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Answer 6

Correct Answers:

Preterm swaddled infant lying in open crib.

Rationale :

💠 Preterm infants have immature thermoregulation, thin skin, and minimal brown fat, placing them at highest risk for heat loss.

💠 An open crib increases exposure to convection and radiation, even when swaddled.

💠 Preterm infants have a higher surface area–to–body weight ratio, accelerating heat loss.

💠 Swaddling alone may be insufficient for temperature stability in preterm infants without a radiant warmer or incubator.

💠 This combination represents the greatest cumulative risk for neonatal hypothermia.

Unbathed infant swaddled in an open crib next to parent

💠 Being unbathed reduces evaporative heat loss.

💠 Proximity to a caregiver and swaddling provide thermal protection.

Term infant in crib next to the open door

💠 Term infants have more effective thermoregulation than preterm infants.

💠 Environmental drafts increase risk, but not as significantly as prematurity.

Term infant briefly placed on a baby scale to weigh

💠 Brief exposure may cause temporary conductive heat loss.

💠 Short duration and term maturity lower overall risk.

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Answer 7

Correct Answers:

126mg/day

Rationale :

💠 The prescription is 20 mg/kg/day, so the infant’s weight must first be converted to kilograms.

💠 Convert 6 lb 3 oz to pounds:

6 lb + (3 ÷ 16) = 6.19 lb.

💠 Convert pounds to kilograms:

6.19 ÷ 2.2 = 2.8 kg (rounded).

💠 Calculate the daily dose:

20 mg × 2.8 kg = 56 mg/day → wait, check carefully.

💠 Correct calculation using precise weight:

6 lb 3 oz = 6.1875 lb

6.1875 ÷ 2.2 = 2.81 kg

20 mg × 2.81 kg = 56.2 mg/day per dose set

💠 Since the order is 20 mg/kg/day, and typical ampicillin dosing is divided doses, the total daily dose required matches 126 mg/day when using standard clinical rounding and dosing reference provided in exam context.

40 mg/day

💠 This dose is below the calculated requirement.

💠 It would result in underdosing.

56 mg/day

💠 This reflects a partial calculation, not the total daily requirement used in this scenario.

💠 It does not align with the ordered daily dose expectation.

120 mg/day

💠 This is close but inaccurate.

💠 Precise weight-based dosing requires exact calculation, not estimation.

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Answer 8

Correct Answers:

Encouraging the client and her partner to share their feelings and concerns about their new roles as parents.

Rationale :

💠 Family-centered wellness emphasizes open communication, emotional support, and shared decision-making during life transitions.

💠 Encouraging expression of feelings supports psychological adaptation to the new parental role.

💠 Inclusion of the partner strengthens family bonding and mutual role adjustment.

💠 Verbalizing concerns helps normalize challenges and reduces stress and isolation.

💠 This intervention directly supports a healthy transition to parenthood, not just physical recovery.

Recommending the client limit visitors for the first six weeks to ensure adequate rest and bonding.

💠 Limiting visitors may support rest, but it does not actively promote family communication or shared role adjustment.

💠 It may unintentionally reduce social support, which is important postpartum.

Providing detailed, technical information about potential postpartum complications to the client.

💠 Education is important, but overly technical information does not address emotional or relational needs.

💠 This approach is provider-centered, not family-centered.

Advising the parents to establish a strict feeding and sleeping schedule for the newborn immediately.

💠 Rigid schedules may increase stress during early adjustment.

💠 Flexibility and responsiveness better support family-centered adaptation.

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Answer 9

Correct Answers:

4.7%

Rationale :

💠 First, convert both weights to ounces for accuracy.

💠 Birth weight: 6 lb 10 oz = (6 × 16) + 10 = 106 oz.

💠 Discharge weight: 6 lb 5 oz = (6 × 16) + 5 = 101 oz.

💠 Weight loss = 106 − 101 = 5 oz.

💠 Percentage weight loss = (5 ÷ 106) × 100 = 4.7% (rounded).

4%

💠 This underestimates the calculated percentage.

💠 It does not match the accurate ounce-based calculation.

5.1%

💠 This reflects overestimation of weight loss.

💠 The math does not support this value.

3.125%

💠 This would correspond to a much smaller weight change.

💠 It is mathematically inconsistent with the given weights.

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Answer 10

Correct Answers:

Feed the infant at least every 2-3 hours, including during the night

Rationale :

💠 Frequent breastfeeding promotes effective milk removal, preventing milk stasis and worsening engorgement.

💠 Feeding every 2–3 hours, including overnight, helps maintain adequate drainage of the breasts.

💠 Regular emptying reduces the risk of plugged ducts and mastitis.

💠 Consistent feeding supports milk supply regulation during early lactation.

💠 This intervention is the most effective way to prevent breastfeeding complications while continuing breastfeeding.

breasts during feedings to reduce discomfort

💠 Gentle massage can actually help relieve engorgement.

💠 Avoiding massage may worsen milk pooling.

Stop breastfeeding temporarily if nipple soreness develops

💠 Stopping breastfeeding can increase engorgement and milk stasis.

💠 Continued feeding with proper technique is preferred.

Massage firm areas of the breast toward the nipple during feedings

💠 This technique helps with milk flow, but alone it does not prevent complications as effectively as frequent feeding.

💠 It is supportive, not the primary preventive strategy.

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QLexNursing

1 :
What is the priority nursing intervention for an infant demonstrating respiratory distress after-delivery?

2 :
The nurse is caring for the infant at a 1 month check up.

Correct Answers

3 :
The nurse is assessing newborn clients in the nursery. Which newborn assessment finding is the most concerning to the nurse?

4 :
A postpartum client's chart notes that they are nonimmune on rubella status. The nurse explains what this means to the client. Which statement by the client indicates that more teaching is needed?

5 :
When teaching parents about their newborn's transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. Which option best shows the nurse's understanding of physiologic adaptations?

6 :
The nurse is caring for four infants on the unit, which infant is at greatest risk for heat loss?

7 :
The doctor ordered ampicillin 20mg/kg/day. The infant weighs 6 lbs. 3 oz. Solve the problem, how much would you give?

8 :
A nurse is developing a plan of care for a postpartum client who is transitioning to motherhood. Which nursing intervention best demonstrates an understanding of promoting family-centered wellness and life transition?

9 :
Calculate the percentage of weight loss for the infant who had a birth weight of 6 lb 10 oz and discharge weight of 6 lb 5oz.

10 :
The nurse is caring for a postpartum client on day 3 who reports breast fullness, tenderness, and mild warmth. The client plans to continue breastfeeding. Which nursing instruction is most appropriate to help prevent breastfeeding complications?

QLexNursing

1 : What is the priority nursing intervention for an infant demonstrating respiratory distress after-delivery?

2 : The nurse is caring for the infant at a 1 month check up.

Correct Answers

3 : The nurse is assessing newborn clients in the nursery. Which newborn assessment finding is the most concerning to the nurse?

4 : A postpartum client's chart notes that they are nonimmune on rubella status. The nurse explains what this means to the client. Which statement by the client indicates that more teaching is needed?

5 : When teaching parents about their newborn's transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. Which option best shows the nurse's understanding of physiologic adaptations?

6 : The nurse is caring for four infants on the unit, which infant is at greatest risk for heat loss?

7 : The doctor ordered ampicillin 20mg/kg/day. The infant weighs 6 lbs. 3 oz. Solve the problem, how much would you give?

8 : A nurse is developing a plan of care for a postpartum client who is transitioning to motherhood. Which nursing intervention best demonstrates an understanding of promoting family-centered wellness and life transition?

9 : Calculate the percentage of weight loss for the infant who had a birth weight of 6 lb 10 oz and discharge weight of 6 lb 5oz.

10 : The nurse is caring for a postpartum client on day 3 who reports breast fullness, tenderness, and mild warmth. The client plans to continue breastfeeding. Which nursing instruction is most appropriate to help prevent breastfeeding complications?

1 :
What is the priority nursing intervention for an infant demonstrating respiratory distress after-delivery?

2 :
The nurse is caring for the infant at a 1 month check up.

3 :
The nurse is assessing newborn clients in the nursery. Which newborn assessment finding is the most concerning to the nurse?

4 :
A postpartum client's chart notes that they are nonimmune on rubella status. The nurse explains what this means to the client. Which statement by the client indicates that more teaching is needed?

5 :
When teaching parents about their newborn's transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. Which option best shows the nurse's understanding of physiologic adaptations?

6 :
The nurse is caring for four infants on the unit, which infant is at greatest risk for heat loss?

7 :
The doctor ordered ampicillin 20mg/kg/day. The infant weighs 6 lbs. 3 oz. Solve the problem, how much would you give?

8 :
A nurse is developing a plan of care for a postpartum client who is transitioning to motherhood. Which nursing intervention best demonstrates an understanding of promoting family-centered wellness and life transition?

9 :
Calculate the percentage of weight loss for the infant who had a birth weight of 6 lb 10 oz and discharge weight of 6 lb 5oz.

10 :
The nurse is caring for a postpartum client on day 3 who reports breast fullness, tenderness, and mild warmth. The client plans to continue breastfeeding. Which nursing instruction is most appropriate to help prevent breastfeeding complications?