A nurse is attending to a newborn who was delivered at 39 weeks of gestation and is now 36 hours old.
The newborn has been breastfeeding 3 to 4 times per day and has voided once since birth but has not passed meconium stool yet.
Which of the following observations should the nurse report to the provider?
Glucose level
Head assessment finding sclera color
Respiratory rate
Intake and output
The Correct Answer is D
Choice A rationale
While monitoring glucose levels is important in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice B rationale
While assessing the newborn’s head and sclera color is part of a comprehensive newborn examination, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice C rationale
While monitoring the newborn’s respiratory rate is crucial in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice D rationale
Monitoring intake and output is directly related to breastfeeding frequency and voiding patterns. A newborn who has been breastfeeding 3 to 4 times per day should have passed meconium stool by 36 hours old. The absence of meconium stool could indicate a problem and should be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While monitoring glucose levels is important in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice B rationale
While assessing the newborn’s head and sclera color is part of a comprehensive newborn examination, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice C rationale
While monitoring the newborn’s respiratory rate is crucial in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice D rationale
Monitoring intake and output is directly related to breastfeeding frequency and voiding patterns. A newborn who has been breastfeeding 3 to 4 times per day should have passed meconium stool by 36 hours old. The absence of meconium stool could indicate a problem and should be reported to the provider.
Correct Answer is C
Explanation
Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.
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