96. Clinical Scenario – Fundal Assessment
A nurse is caring for a postpartum client 2 hours after delivery. The uterus is deviated to the
right and boggy.
What is the first nursing action?
1. Call the healthcare provider
2. Begin oxytocin infusion
3. Assist the client to void
4. Document the finding
97. Priority Action – Magnesium Sulfate Toxicity
A nurse is caring for a client receiving magnesium sulfate for preeclampsia. The client has RR
of 10/min, absent deep tendon reflexes, and reports feeling "heavy."
What is the priority nursing action?
1. Discontinue the infusion
2. Increase IV fluid rate
3. Administer calcium gluconate
4. Place the client in high Fowler’s position
98. Newborn Assessment – NAS
A newborn born to a mother with opioid use disorder is irritable, has a high-pitched cry, and
poor feeding.
Which action should the nurse take first?
1. Perform a blood glucose test
2. Minimize environmental stimuli and swaddle the newborn
3. Offer formula feeding immediately
4. Administer naloxone
99. Discharge Teaching – Umbilical Cord Care
Which instruction should the nurse include when teaching a parent about newborn umbilical
cord care?
1. Clean the base with alcohol at each diaper change
2. Keep the cord moist and covered
3. Fold the diaper below the cord stump
4. Apply antibiotic ointment daily
100. Danger Signs – Newborn Emergency
Which finding should the parent report immediately after discharge?
1. Yellowing of skin on day 2
2. Temperature of 100.4°F (38°C)
