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A nurse is assisting with the care of a newborn 1 hr following birth.

Exhibits

Select the 5 findings that the nurse should report to the provider.

Temperature

Respiratory findings

Serum glucose

Hematocrit

White blood cell count

Hemoglobin

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Holding the newborn vertically, allowing one foot to touch the crib surface, will elicit the stepping reflex, not the Moro reflex. The stepping reflex is when the newborn makes stepping movements when held upright with one foot touching a flat surface.

Choice B reason:

Turning the newborn's head quickly to one side will elicit the tonic neck reflex, not the Moro reflex. The tonic neck reflex is when the newborn assumes a "fencing”. position, with the arm and leg extended on the side to which the head is turned and the opposite arm and leg flexed.

Choice C reason:

Performing a sharp hand clap near the infant will elicit the Moro reflex, also known as the startle reflex. The Moro reflex is when the newborn responds to a sudden loss of support or a loud noise by extending and abducting the arms, spreading the fingers, and then bringing the arms together and crying.

Choice D reason:

Placing a finger at the base of the newborn's toes will elicit the Babinski reflex, not the Moro reflex. The Babinski reflex is when the newborn fans out the toes and dorsiflexes the big toe when the sole of the foot is stroked.

A. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor.". B. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.". C. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days.". D. "This is a Mongolian spot, which is found on many newborns.".

Correct Answer is A

Explanation

Choice A reason:

This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.

Choice B reason:

This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.

Choice C reason:

This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.

Choice D reason:

This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.

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A nurse is assisting with the care of a newborn 1 hr following birth. Exhibits Select the 5 findings that the nurse should report to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?

Correct Answer is C

Explanation

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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A nurse is assisting with the care of a newborn 1 hr following birth.

Exhibits

Select the 5 findings that the nurse should report to the provider.