A nurse is caring for a newborn 1 hr following birth.
The newborn was delivered via emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate. The Apgar score was 5 at 1 min.
Positive pressure ventilation was given for 1 min followed by free flow oxygen.
What finding should the nurse report to the provider?
Hemoglobin
Hematocrit
Serum glucose
Respiratory assessment
Temperature
The Correct Answer is D
Choice A rationale
Hemoglobin is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice B rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it is an important parameter to monitor in newborns, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice C rationale
Serum glucose is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice D rationale
A respiratory assessment is crucial for a newborn, especially one that has undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non- reassuring fetal heart rate. The newborn’s Apgar score was 5 at 1 min, which indicates significant distress, and positive pressure ventilation was given for 1 min followed by free flow oxygen. These factors make respiratory assessment a priority and one of the immediate findings that the nurse should report to the provider.
Choice E rationale
Temperature is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, it’s common for women to have difficulty emptying their bladder. If the bladder becomes too full, it can push the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with a distended bladder. After childbirth, it’s normal for women to experience contractions as the uterus begins to shrink back to its pre-pregnancy size.
Choice C rationale
Increased thirst is not typically a sign of a distended bladder. It’s common for women to feel thirsty as their body adjusts after childbirth.
Choice D rationale
Less than 2.5 cm of rubra lochia on the perineal pad is not typically a sign of a distended bladder. Lochia is the vaginal discharge women experience after childbirth. It’s not related to bladder function.
Correct Answer is C
Explanation
Choice A rationale
Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.
Choice B rationale
Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.
Choice C rationale
This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice D rationale
Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.
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