A nurse is assisting with the care of a newborn 1 hr after birth.
Select the 5 findings that the nurse should report to the provider.
Temperature
Respiratory findings
Serum glucose
Hematocrit
White blood cell count
Hemoglobin
Heart rate
Correct Answer : B,F,G
Choice A:
Temperature. The newborn's temperature is within the normal range of 36.5°C to 37.5°C (97.7°F to 99.5°F) for axillary measurement. Therefore, this finding does not need to be reported to the provider.
Choice B:
Respiratory findings. The newborn's respiratory rate is above the normal range of 30 to 60 breaths per minute. The newborn also has a low oxygen saturation of 96%, which indicates possible respiratory distress. Therefore, this finding should be reported to the provider.
Choice C:
Serum glucose. The question does not provide any information about the newborn's serum glucose level, so this choice is irrelevant and does not need to be reported to the provider.
Choice D:
Hematocrit. The question does not provide any information about the newborn's hematocrit level, so this choice is irrelevant and does not need to be reported to the provider.
Choice E:
White blood cell count. The question does not provide any information about the newborn's white blood cell count, so this choice is irrelevant and does not need to be reported to the provider.
Choice F:
Hemoglobin. The question does not provide any information about the newborn's hemoglobin level, but it is known that newborns have higher hemoglobin levels than adults due to fetal hemoglobin. A high hemoglobin level can increase the risk of polycythemia, which can cause hyperviscosity, hypoxia, and hyperbilirubinemia. Therefore, this finding should be reported to the provider.
Choice G:
Heart rate. The newborn's heart rate is above the normal range of 110 to 160 beats per minute. A high heart rate can indicate tachycardia, which can be caused by various factors such as fever, dehydration, anemia, infection, or congenital heart defects. Therefore, this finding should be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Preterm birth is a major risk factor for neonatal sepsis, especially early-onset sepsis. Preterm babies have immature immune systems and lack antibodies to protect them against certain bacteria.
Choice B reason:
Cesarean birth is not a risk factor for neonatal sepsis by itself, unless it is associated with other factors such as prolonged rupture of membranes, maternal infection or chorioamnionitis.
Choice C reason:
Precipitous delivery is a risk factor for neonatal sepsis, especially early-onset sepsis. Precipitous delivery can cause fetal distress, hypoxia, acidosis and increased susceptibility to infection.
Choice D reason:
Frequent vaginal exams are a risk factor for neonatal sepsis, especially early-onset sepsis. Frequent vaginal exams can introduce bacteria into the amniotic fluid and increase the risk of ascending infection.
Choice E reason:
Mother has GBS infection is a risk factor for neonatal sepsis, especially early-onset sepsis. GBS (group B streptococcus) is the most common cause of early-onset neonatal sepsis and can be transmitted from the mother to the baby during labor and delivery.
Correct Answer is D
Explanation
Choice A reason:
Injury sustained to the perineum during birth is not a perinatal injury, but a perineal injury. The perineum is the area between the anus and the genitals, and it can be torn or cut during vaginal delivery. This is a common complication that affects the mother, not the fetus or newborn.
Choice B reason:
Traumatic injury to the mother during pregnancy is not a perinatal injury, but a maternal injury. This can occur due to accidents, violence, or complications of pregnancy such as preeclampsia or placental abruption. This can affect the mother's health and well-being, and may also have consequences for the fetus or newborn.
Choice C reason:
Traumatic injury to a fetus is not a perinatal injury, but a fetal injury. This can occur due to external forces such as blunt trauma, penetrating trauma, or radiation exposure that affect the fetus in utero. This can cause fetal distress, bleeding, fractures, or organ damage.
Choice D reason:
Injury sustained surrounding birth is a perinatal injury. This occurs in the period shortly before, during, or after delivery. This can be a critical time when the baby has to transition from surviving off oxygen, blood, and nutrients from the mother to separating from the womb and breathing oxygen from the air. Perinatal injuries can include head injuries, nerve injuries, hemorrhages, fractures, or soft-tissue injuries that result from the forces of labor and delivery or medical interventions such as forceps or vacuum extraction. Perinatal injuries can lead to long-term neurodevelopmental challenges for the newborn.
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