A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

A newborn who is 8 hr old and has acrocyanosis.

A newborn who is 18 hr old and has not voided.

A newborn who is 24 hr old and has not passed meconium.

A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.

Choice B rationale:

A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.

Choice C rationale:

A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.

Choice D rationale:

The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.

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Correct Answer is C

Explanation

Choice A rationale:

Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.

Choice B rationale:

Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.

Choice C rationale:

Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.

A. The newborn with significant bruising from a face presentation. B. The premature newborn. C. The baby born at 41 weeks' gestation. D. The newborn with O+ blood type, born to a mother with O- blood type.

Correct Answer is C

Explanation

Choice A rationale:

(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.

Choice B rationale:

(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.

Choice C rationale:

(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.

Choice D rationale:

(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.

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A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?

Correct Answer is C

Explanation

A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

A mother asks, "Why does my infant have blue hands?".

A nurse is caring for a newborn who is formula-fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?

The nurse is most concerned about which assessment finding?

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?