A nurse is attending to a newborn 2 hours after birth.
Which four observations should the nurse report to the healthcare provider?
Body temperature.
Respiratory assessment.
Serum glucose level.
White blood cell count.
The Correct Answer is C
Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Gravida 4 Para 3 at 33 weeks of gestation is not an alarming finding. It simply indicates that the woman is pregnant for the fourth time and has had three previous deliveries. This is a normal part of the woman’s obstetric history and does not need to be reported to the provider.
Choice B rationale
Allergies, such as a sulfa allergy, are important to note in the patient’s medical history. However, unless the patient is being prescribed a medication that she is allergic to, this information does not need to be urgently reported to the provider.
Choice C rationale
A height of 165 cm (66 in), weight of 82 kg (180 lb), and BMI of 30.6 are all within normal ranges for a pregnant woman. These measurements are part of routine prenatal care and do not need to be urgently reported to the provider.
Choice D rationale
A weight gain of 32 kg (7 lb) over the last 2 weeks is concerning. Rapid weight gain can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. This should be reported to the provider immediately.
Correct Answer is B
Explanation
Choice A rationale
Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.
Choice B rationale
Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.
Choice C rationale
Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.
Choice D rationale
Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.
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