A nurse is caring for a 36-hour-old male newborn who was born at 39 weeks of gestation in the neonatal intensive care unit (NICU). The newborn has been breastfeeding 3 to 4 times per day and has voided once since birth but has not passed meconium stool since birth. The nurse notes that the newborn’s sclera appears yellow.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Positive Coombs test
Glucose level
Scleía coloí
Absence of meconium stool
Head assessment finding
Heart rate
Respiratory rate
Mucous membíane assessment
Correct Answer : A,C,D,F,G,H
Choice A rationale: A positive Coombs test indicates that the newborn has antibodies against his own red blood cells, which can lead to hemolytic disease of the newborn. This condition can cause severe anemia and jaundice, which can lead to complications such as kernicterus if not treated promptly.
Choice B rationale: The newborn’s glucose level is within the normal range (40 to 60 mg/dL), so this finding does not require immediate follow-up.
Choice C rationale: The yellow color of the sclera indicates jaundice, which can be a sign of hyperbilirubinemia. This condition can lead to complications such as kernicterus if bilirubin levels become too high.
Choice D rationale: The absence of meconium stool in a 36-hour-old newborn is unusual, as most newborns pass meconium within the first 24 to 48 hours after birth. This could indicate a problem such as meconium ileus or Hirschsprung disease, which would require further evaluation.
Choice E rationale: The head assessment finding of caput succedaneum is a common and typically harmless condition in newborns caused by pressure on the head during delivery. It does not require immediate follow-up.
Choice F rationale: The newborn’s heart rate is slightly elevated (normal range for a newborn is 120-160 beats per minute). This could be a response to factors such as fever, pain, or distress, and should be reported to the provider.
Choice G rationale: The newborn’s respiratory rate is also elevated (normal range for a newborn is 30-60 breaths per minute). This could be a sign of respiratory distress and should be reported to the provider.
Choice H rationale: Dry mucous membranes can be a sign of dehydration, which can occur if the newborn is not feeding well or is losing too much fluid, for example, through excessive sweating due to fever. This should be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Performing a fundal massage is not the appropriate action for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Fundal massage is typically used to stimulate contractions and reduce postpartum hemorrhage after the delivery of the placenta. However, in the case of placenta previa, where the placenta is covering the cervix, a fundal massage could potentially cause more harm and increase bleeding.
Choice B rationale
Assessing for abdominal tenderness is not the most immediate action for a nurse to take when a client with placenta previa is exhibiting a large amount of vaginal bleeding. While abdominal tenderness could indicate a complication such as placental abruption, the primary concern with placenta previa is the risk of severe bleeding that can endanger both the mother and the baby.
Choice C rationale
Obtaining serial hemoglobin and hematocrit is the correct action in this situation. These laboratory tests are important for monitoring the client’s blood loss and determining the need for a possible blood transfusion. With a large amount of vaginal bleeding, the client is at risk for anemia and hypovolemic shock, so close monitoring of blood levels is crucial.
Choice C rationale
Monitoring vital signs closely is an important part of care for any client, but it is not the most specific action a nurse should take for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Vital sign changes could indicate worsening of the client’s condition, but these changes often occur late in the progression of blood loss. Therefore, while important, it is not the most immediate action to take.
Correct Answer is B
Explanation
Choice A rationale
Transient occipital cyanosis is not a clinical finding that should be reported to the provider. It is a normal finding in newborns due to immature circulation and should resolve on its own.
Choice B rationale
Single palmar creases, also known as simian lines, can be a sign of certain genetic conditions, such as Down syndrome. Therefore, this finding should be reported to the provider.
Choice C rationale
Subconjunctival hemorrhage, or a red spot in the white of the eye, is a common and harmless condition in newborns. It does not require treatment and will disappear as the blood is absorbed.
Choice D rationale
Dystocia, or difficult labor, is not a clinical finding in a newborn. It refers to a situation during childbirth where there is slow or difficult labor or delivery.
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