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
While magnesium sulfate can have an effect on the fetal heart rate, it does not primarily function to stabilize it. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties.
Choice B rationale
Magnesium sulfate does not primarily function to improve tissue perfusion. Its main role in the management of preeclampsia is to prevent seizures.
Choice C rationale
This is the correct answer. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties. It helps to prevent seizures in those with severe preeclampsia, which can minimize the risk of complications.
Choice D rationale
Magnesium sulfate does not increase cardiac output. Its primary role in the management of preeclampsia is to prevent seizures.
Correct Answer is D
Explanation
The correct answer is choiced. Inform the client about the possible need for reduction of multiple fetuses.
Choice A rationale:
Instructing the client not to use donor oocytes is not accurate.Donor oocytes can be a viable option for clients with certain infertility issues, such as ovarian insufficiency or genetic concerns.
Choice B rationale:
Informing the client that sperm will be introduced to the uterus during ovulation is incorrect.In vitro fertilization involves fertilizing the eggs outside the body in a laboratory setting, not directly introducing sperm into the uterus.
Choice C rationale:
Instructing the client to avoid freezing embryos for possible use in the future is not appropriate.Freezing embryos is a common practice in IVF to allow for future attempts if the initial cycle is unsuccessful.
Choice D rationale:
Informing the client about the possible need for reduction of multiple fetuses is correct.IVF can result in multiple pregnancies, and in some cases, fetal reduction may be recommended to ensure the health and safety of the mother and remaining fetuses.
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.