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 B
Explanation
Choice A reason:
Determining maternal well-being is not the purpose of the Bishop's score. The Bishop's score is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It does not measure maternal vital signs, blood tests, or other indicators of maternal well-being.
Choice B reason:
Determining the readiness of the cervix for labor is the purpose of the Bishop's score. The Bishop's score gives points to five measurements of the pelvic examination: dilation, effacement, station, consistency, and position of the cervix. The higher the score, the more favorable or "ripe”. the cervix is for induction of labor.
Choice C reason:
Determining the progress of labor is not the purpose of the Bishop's score. The Bishop's score is used before labor begins to assess the likelihood of a successful induction or a spontaneous preterm delivery. It does not measure contractions, fetal descent, or other indicators of labor progress.
Choice D reason:
Determining the well-being of the fetus is not the purpose of the Bishop's score. The Bishop's score is a cervical assessment tool that does not directly evaluate fetal status. It does not measure fetal heart rate, movement, or biophysical profile.
Correct Answer is B
Explanation
Choice A reason:
Swimming is one of the best and safest exercises for pregnant women. It exercises your large muscle groups, provides cardiovascular benefits, reduces swelling, and allows you to feel weightless. Swimming is also a low-impact exercise that does not put too much stress on your joints and muscles. Therefore, this statement does not indicate a need for additional teaching.
Choice B reason:
Racquetball is not an appropriate exercise during pregnancy. It is a high-impact sport that involves sudden changes of direction, quick movements, and the risk of falling or getting hit by the ball or the racquet. These factors can increase the chance of injury, bleeding, or premature labor. Therefore, this statement indicates a need for additional teaching.
Choice C reason:
Cycling on a stationary bike is a safe exercise during pregnancy. It provides moderate aerobic conditioning and relieves stress and tension in your joints and muscles. Cycling on a stationary bike also reduces the risk of falling or losing balance compared to cycling on a regular bike. Therefore, this statement does not indicate a need for additional teaching.
Choice D reason:
Yoga is a beneficial exercise during pregnancy. It can help you relax, improve your flexibility, strengthen your muscles, and prepare your body for labor and delivery. Yoga can also help you cope with symptoms of depression and anxiety during pregnancy. However, you should avoid hot yoga or poses that involve lying flat on your back, twisting your abdomen, or compressing your belly. Therefore, this statement does not indicate a need for additional teaching.
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