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
Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.
Choice B rationale
While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.
Choice C rationale
Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.
Choice D rationale
Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response, “You seem scared to talk to your parents,” is an empathetic response that validates the client’s feelings and encourages further communication. It’s important for the nurse to provide emotional support and help the client explore her feelings about the situation. The nurse can also provide information about confidentiality laws and discuss potential outcomes of various decisions.
Choice B rationale
Telling the client that her parents will have to be told why she is being admitted may not be accurate depending on the age of the client and local laws regarding minor’s rights to privacy in healthcare. It’s crucial to respect the client’s autonomy and privacy.
Choice C rationale
While it’s possible that the parents might understand, suggesting this puts pressure on the client to disclose her condition to her parents. The nurse should instead focus on supporting the client in making her own decision about disclosure.
Choice D rationale
Offering to tell the parents for the client could undermine the client’s autonomy and may not be legally permissible without the client’s consent. The nurse should instead focus on helping the client explore her options and come to her own decision.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.