Baby H. was just born in a hospital that provides single-room maternity care (SRMC). SRMC allows the
infant to remain with the parents after birth. H.'s mother was in labor for 12 hours and gave birth vagi-
nally.
Baby H. is the first baby born to these parents. The nurse will complete the physical assessment and
observe for physiologic changes in the infant's transition from intrauterine to extrauterine life.
Name the three phases that occur during this transition period and state an approximate
time frame for each.
Variations of the timing will be seen in actual practice.
1, First period of reactivity, lasting up to 30 minutes after birth.
2, Sleep phase, lasting from 60 to 100 minutes.
3, Second period of reactivity, occurring 4 to 8 hours after birth and lasting from 10 minutes to a few
hours.
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During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort
A nurse is inserting a nasogastric (NG) tube for an adult client. During the procedure, the client begins to cough and have difficulty breathing. The priority action at this time is which of the following?
1. Quickly insert the NG tube. 2. Remove the tube, and notify the physician. 3. Remove the tube, and reinsert when the client fully recovers. 4. Pull back on the tube, and wait until the client is breathing easily.
Patients may be smiling, talking, or sleeping and still be having pain.
Answer the following statement true (T) or false (F)
Which action will the nurse take when it is determined that the narcotic count is incorrect while obtaining a medication from the narcotic area?
a. Determine the cause of the discrepancy at the end of the shift. b. Notify the health care provider stat. c. Call the nurse from the previous shift to determine if there was a discrepancy earlier. d. Report the discrepancy to the charge nurse immediately.