A nurse is assessing a full-term newborn who is 24 hr old. Which of the following findings should the nurse report to the provider?
The newborn's neck is short and surrounded by skin folds.
The newborn's glucose level is 50 mg/dL
The newborn's sclerae have a yellowish tint
The newborn has experienced a weight loss of 3% since birth
The Correct Answer is C
A. The newborn's neck is short and surrounded by skin folds: A short neck with skin folds can be a normal variant in some newborns, especially those with subcutaneous fat. While it may warrant observation for potential anomalies, it is not an immediate concern at 24 hours of age.
B. The newborn's glucose level is 50 mg/dL: A glucose level of 50 mg/dL is within the normal range for a full-term newborn. Routine monitoring is sufficient, and this finding does not require urgent reporting.
C. The newborn's sclerae have a yellowish tint: Jaundice appearing within the first 24 hours of life can indicate pathological jaundice, which may result from hemolysis, infection, or metabolic disorders. Early-onset jaundice requires prompt evaluation and intervention to prevent complications such as kernicterus.
D. The newborn has experienced a weight loss of 3% since birth: A weight loss of up to 5–7% in the first few days after birth is considered normal due to fluid shifts. A 3% loss is expected and does not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6.2"]
Explanation
Rationale:
- Identify the ordered dose and client weight
Ordered Dose: 0.15 mg/kg
Client Weight: 41 kg
- Calculate the dose to administer
Dose to administer = Ordered Dose × Client Weight
Dose to administer = 0.15 × 41
Dose to administer = 6.15 mg
Correct Answer is B
Explanation
A. Decreased level of consciousness: This is a late sign of hypoxia, indicating significant oxygen deprivation and possible brain involvement. Immediate intervention is required at this stage.
B. Restlessness: Restlessness is an early clinical manifestation of hypoxia. It reflects the body’s initial response to inadequate oxygenation, often presenting as anxiety, irritability, or agitation, and should prompt further assessment and intervention.
C. Circumoral cyanosis: Cyanosis around the mouth is a late sign of hypoxia, typically appearing after prolonged oxygen deprivation when oxygen saturation has significantly dropped.
D. Seizures: Seizures occur only in severe, prolonged hypoxia or hypoxemia affecting the central nervous system. This is a late and serious indicator of oxygen deprivation.
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