A nurse is assisting with the care of a newborn 1 hr following birth.
Select the 5 findings that the nurse should report to the provider.
Temperature
Respiratory findings
Serum glucose
Hematocrit
White blood cell count
Hemoglobin
Correct Answer : B,C,D,F,G
Choice A:
Temperature is not a finding that the nurse should report to the provider. The normal range for temperature in newborns is 36.5 to 37 degrees Celsius axillary. The question does not provide the temperature of the newborn, but it does not indicate any signs of hypothermia or hyperthermia.
Choice B:
Respiratory findings are findings that the nurse should report to the provider. The newborn has mild grunting, nasal flaring, and intermittent retractions, which are signs of respiratory distress. These could indicate a problem with lung development, infection, or congenital heart disease.
Choice C:
Serum glucose is a finding that the nurse should report to the provider. The normal range for blood glucose in newborns is above 40 mg/dL. The question does not provide the serum glucose level of the newborn, but it could be low due to factors such as prematurity, maternal diabetes, or sepsis.
Choice D:
Hematocrit is a finding that the nurse should report to the provider. The normal range for hematocrit in newborns is 42% to 65%. The question does not provide the hematocrit level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice E:
White blood cell count is not a finding that the nurse should report to the provider. The normal range for white blood cell count in newborns is 9,000 to 30,000/mm3. The question does not provide the white blood cell count of the newborn, but it does not indicate any signs of infection or inflammation.
Choice F:
Hemoglobin is a finding that the nurse should report to the provider. The normal range for hemoglobin in newborns is 14 to 24 g/dL. The question does not provide the hemoglobin level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice G:
Heart rate is a finding that the nurse should report to the provider. The normal range for heart rate in newborns is 85 to 190 beats per minute when awake. The question does not provide the heart rate of the newborn, but it could be high due to stress, pain, fever, or hypoxia, or low due to bradycardia or cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Attachment phase is not one of Rubin's phases of role attachment. Rubin's theory of maternal role adaptation describes three stages that the mother goes through during the postpartum period: taking in, taking hold and letting go.
Choice B reason:
Letting go phase is the last stage of Rubin's theory of role attachment. It occurs when the mother accepts her new role and gives up her old roles. She also comes to terms with the reality of the birthing experience and the characteristics of her baby.
Choice C reason:
Taking hold phase is the second stage of Rubin's theory of role attachment. It occurs when the mother becomes interested in caring for the infant and learning about her baby and herself. She may be critical about her care-giving abilities and need positive reinforcement.
Choice D reason:
Taking in phase is the first stage of Rubin's theory of role attachment. It occurs right after the birth of the child, when the mother is passive and focused on her own needs, especially sleeping and eating. She may have limited interactions with her infant and prefer to talk about her experiences during labor, birth, and pregnancy. This matches the description of the new mother in the question, so this is the correct answer.
Correct Answer is D
Explanation
Choice A reason:
A soft fundus indicates uterine atony, which is a lack of muscle tone that can lead to postpartum hemorrhage. A soft fundus is an abnormal finding and should be reported to the provider. The fundus should be firm and contracted to prevent bleeding.
Choice B reason:
A fundus that is 2 fingerbreadths above the umbilicus is too high for a client who is 12 hours postpartum. The fundus should descend about 1 centimeter per hour after delivery and should be at the level of the umbilicus at 12 hours postpartum. A high fundus could indicate retained placental fragments or a full bladder, both of which can interfere with uterine contraction and cause bleeding.
Choice C reason:
A fundus that is deviated to the right of the umbilicus is also an abnormal finding for a client who is 12 hours postpartum. A deviated fundus could indicate a full bladder, which can displace the uterus and prevent it from contracting properly. The fundus should be at the midline of the abdomen.
Choice D reason:
A fundus that is firm and at the level of the umbilicus is a normal finding for a client who is 12 hours postpartum. This indicates that the uterus is involuting (returning to its pre-pregnancy size and shape) and that there is no excessive bleeding. The nurse should expect this finding and document it accordingly.
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