A nurse is assisting with the care of a newborn who was born at 39 weeks of gestation and is 36 hr old.
Assessment
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants
Which of the following findings should the nurse report to the RN7 Select all that apply.
Glucose level
Mucous membrane assessment
Respiratory rate
Sclera color
Intake and output
Coombs test result
Heart rate
Head assessment finding
Correct Answer : B,D,F,H
A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Calcium is important for bone health but is not directly related to increasing maternal blood volume.
B) Incorrect- Vitamin E is an antioxidant that helps protect cells from damage but is not directly related to increasing maternal blood volume.
C) Correct - Iron is essential for hemoglobin production, which is necessary to support the increase in maternal blood volume during pregnancy.
D) Incorrect- Vitamin D is important for bone health and calcium absorption but is not directly related to increasing maternal blood volume.
Correct Answer is C
Explanation
A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.
B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.
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