62. Complex Case-Based - Neonatal Hypoxia
A newborn delivered via emergency cesarean at 32 weeks shows nasal flaring, grunting,
intercostal retractions, and O2 saturation of 84% on room air.
Which nursing interventions should be initiated? Select all that apply.
1. Administer oxygen therapy
2. Delay feeding until respiratory distress resolves
3. Prepare for exogenous surfactant administration
4. Keep newborn swaddled for warmth
5. Monitor blood gases and respiratory effort
63. Multi-Step Decision-Making - Postpartum Hemorrhage Emergency
A postpartum client who delivered twins continues to have heavy bleeding despite fundal
massage and oxytocin infusion. BP is 75/40 mmHg, HR is 138 bpm, and skin is cold and
clammy.
Which action should the nurse take next?
1. Administer carboprost or misoprostol per protocol
2. Offer fluids and reassess
3. Apply abdominal binders
4. Encourage breastfeeding
64. Priority Nursing Action - Shoulder Dystocia Emergency
During delivery, the fetal head retracts back against the perineum ("turtle sign"), signaling
shoulder dystocia.
What is the priority nursing intervention?
1. Apply fundal pressure
2. Perform McRoberts maneuver and apply suprapubic pressure
3. Encourage maternal pushing
4. Notify NICU team
65. Advanced Critical Thinking - Neonatal Sepsis Risk
A 3-hour-old newborn born to a mother with prolonged rupture of membranes (PROM) has
temperature instability, poor feeding, and tachypnea.
Which interventions are appropriate? Select all that apply.
1. Obtain blood cultures and start antibiotics
2. Delay feeding until symptoms improve
3. Monitor respiratory status closely
4. Keep newborn swaddled at all times
5. Assess for lethargy or irritability
60. Complex Decision-Making - Newborn Sepsis
