A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old.
Which of the following findings should the nurse report to the provider? Select all that apply.
Glucose level.
Head assessment finding.
Coombs test result.
Sclera color.
Heart rate.
Intake and output.
Mucous membrane assessment.
Respiratory rate
Correct Answer : D,F,G
Choice A rationale:
Glucose level is within the normal range (40 to 60 mg/dL), so it's not a complication.
Choice B rationale:
Caput succedaneum is a common finding in newborns who were delivered vaginally and is not a complication.
Choice C rationale:
A negative Coombs test is a normal finding and does not indicate a complication.
Choice D rationale:
Yellow sclera in a newborn can be a sign of jaundice, which should be reported to the provider.
Choice E rationale:
Heart rate is slightly elevated but within the normal range for a newborn (100-160/min), so it's not a complication.
Choice F rationale:
The newborn has not passed meconium stool since birth, which should be reported to the provider as it could indicate a complication.
Choice G rationale:
Dry mucous membranes can be a sign of dehydration, which should be reported to the provider.
Choice H rationale:
Respiratory rate is within the normal range for a newborn (30-60/min), so it's not a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","H"]
Explanation
Choice A rationale:
BUN is within the normal range (10 to 20 mg/dL), so it's not an indication of a potential complication.
Choice B rationale:
Potassium is slightly below the normal range (3.5 to 5 mEq/L), indicating potential hypokalemia, which can be a complication.
Choice C rationale:
Hct is at the upper limit of the normal range (33% to 49%), but still within normal, so it's not a complication.
Choice D rationale:
Weight loss of 2 kg in 1 month during pregnancy is concerning and could indicate a complication such as hyperemesis gravidarum.
Choice E rationale:
Heart rate is slightly elevated, which could indicate dehydration, a potential complication.
Choice F rationale:
Sodium is slightly below the normal range (136 to 145 mEq/L), but this alone is not typically a complication of pregnancy.
Choice G rationale:
Hgb is within the normal range (11 to 16 g/dL), so it's not a complication.
Choice H rationale:
Urine-specific gravity is above the normal range (1.005 to 1.030), indicating potential dehydration, a complication.
Correct Answer is D
Explanation
Choice A rationale:
Uterine hypertonicity is associated with labor complications, not placenta previa.
Choice B rationale:
A persistent headache is not a typical symptom of placenta previa.
Choice C rationale:
A firm, rigid abdomen is a sign of a possible uterine rupture, not placenta previa.
Choice D rationale:
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is correct.
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