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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.
Correct Answer is C
Explanation
Choice A rationale
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Diminished deep tendon reflexes are not typically associated with NAS3.
Choice B rationale
The Moro reflex, also known as the startle reflex, is one of the many reflexes that babies are born with. An absent Moro reflex is not typically associated with NAS3.
Choice C rationale
Excessive crying is a common symptom of NAS. Babies with NAS are often irritable and hard to comfort.
Choice D rationale
Decreased muscle tone is not typically associated with NAS. In fact, babies with NAS often have increased muscle tone, which can result in tight muscle tone and difficulty relaxing muscles.
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