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 A
Explanation
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Documenting the findings and continuing to monitor the client is appropriate because the nurse has already observed that the fundus is midline and firm, which indicates good uterine tone. The presence of lochia rubra and small clots is expected in the immediate postpartum period.
Choice B rationale: Encouraging the client to empty her bladder can help maintain uterine tone, but in this scenario, the fundus is already firm and midline, so this is not the priority action.
Choice C rationale: Notifying the client's provider is unnecessary at this time because the findings are within normal postpartum expectations and the uterus is firm.
Choice D rationale: Increasing the frequency of fundal massage is not needed because the uterus is already firm and midline, indicating that it is contracting properly.
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