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
Explanation
Choice A reason:
FAS is caused by alcohol, and NAS is caused by opioids. This is the correct answer because FAS stands for fetal alcohol syndrome, which is a condition that affects the development of a baby when the mother drinks alcohol during pregnancy. NAS stands for neonatal abstinence syndrome, which is a group of problems that can happen when a baby is exposed to opioid drugs for a length of time while in their mother's womb.
Choice B reason:
FAS and NAS are both incurable. This is incorrect because FAS and NAS are not diseases, but conditions that result from prenatal exposure to substances. FAS and NAS can cause various physical, mental, and behavioral problems in the baby, some of which may be permanent, but others may be improved with early intervention and treatment.
Choice C reason:
FAS is caused by analgesics and NAS is caused by NSAIDs. This is incorrect because analgesics are painkillers, and NSAIDs are nonsteroidal anti-inflammatory drugs. Neither of these types of drugs is known to cause FAS or NAS. However, some analgesics, such as codeine and oxycodone, are opioids and can cause NAS if used by pregnant women.
Choice D reason:
FAS and NAS are both curable. This is incorrect because FAS and NAS are not diseases, but conditions that result from prenatal exposure to substances. FAS and NAS can cause various physical, mental, and behavioral problems in the baby, some of which may be permanent, but others may be improved with early intervention and treatment. However, there is no cure for FAS or NAS.
Correct Answer is A
Explanation
Choice A reason:
Hypoglycemia is a common complication for newborns whose mothers have diabetes mellitus. This is because the newborn's pancreas produces excessive insulin in response to the high glucose levels in the mother's blood during pregnancy. After birth, the newborn's glucose levels drop rapidly, while the insulin levels remain high, resulting in hypoglycemia. The nurse should monitor the newborn's blood glucose levels and signs of hypoglycemia, such as jitteriness, lethargy, poor feeding, and temperature instability.
Choice B reason:
Decreased RBC is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have increased RBC due to chronic fetal hypoxia caused by placental insufficiency. The nurse should monitor the newborn's hematocrit and signs of polycythemia, such as ruddy skin, jaundice, and respiratory distress.
Choice C reason:
Hyperbilirubinemia is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have increased bilirubin levels due to hemolysis of excess RBC and delayed hepatic clearance. The nurse should monitor the newborn's serum bilirubin levels and signs of jaundice, such as yellow skin and sclera, poor feeding, and lethargy.
Choice D reason:
Hypercalcemia is not a likely complication for newborns whose mothers have diabetes mellitus. In fact, these newborns may have hypocalcemia due to decreased parathyroid hormone secretion and increased calcium binding to albumin. The nurse should monitor the newborn's serum calcium levels and signs of hypocalcemia, such as jitteriness, tremors, seizures, and cardiac arrhythmias.
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