A nurse is caring for a mother who delivered vaginally 2 hours ago.
Hemoglobin: 9 g/dL (11 to 14 g/dL). Hematocrit: 30% (36 to 43%). Platelets: 220,000/mm³ (150,000 to 400,000/mm³). WBC count: 12,000/mm³ (4,000 to 15,000/mm³). Temperature: 38.3°C (100.9°F). Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at the vagina.
Correct Answer : B,D
Choice A rationale
Respiratory assessment is important but not immediately concerning without specific abnormal findings.
Choice B rationale
Hemoglobin level of 9 g/dL is low and could indicate postpartum hemorrhage or anemia, warranting attention.
Choice C rationale
Heart rate abnormalities would be significant but are not provided in the data given.
Choice D rationale
Constant trickle of blood at the vagina suggests ongoing bleeding which could indicate a postpartum hemorrhage, requiring prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cephalohematoma is a collection of blood between a newborn's scalp and the skull bone, often caused by birth trauma, but it's not specifically related to small for gestational age (SGA) assessment.
Choice B rationale
Hypoglycemia is a common concern in SGA newborns because they have less stored glucose and glycogen, making blood glucose level monitoring critical.
Choice C rationale
Necrotizing enterocolitis is a serious condition in premature newborns involving inflammation and damage to the intestines, but it is not specific to SGA newborns.
Choice D rationale
Immature reflexes are assessed in newborns, but hypoglycemia takes priority in SGA newborns due to their higher risk of low blood sugar.
Correct Answer is A
Explanation
Choice A rationale
Frequent bowel movements help excrete bilirubin, which reduces jaundice. Newborns pass meconium and transitional stools frequently, aiding in bilirubin clearance.
Choice B rationale
A stable temperature is important for overall health, but it does not specifically impact bilirubin levels or jaundice.
Choice C rationale
A newborn should have 6-8 voids per day indicating good hydration, but it is not directly related to reducing jaundice.
Choice D rationale
A heel stick with a glucose level of 60 may indicate glucose monitoring but is not related to jaundice management.
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