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
Painless vaginal bleeding at 28 weeks of gestation can be a sign of placenta previa or placental abruption, both of which are serious conditions that require immediate attention.
Choice B rationale
While vaginal spotting after a missed period could indicate early pregnancy, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
Choice C rationale
Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a medical emergency.
Choice D rationale
A cough and fever at 38 weeks of gestation could indicate an infection, which should be evaluated. However, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
Correct Answer is D
Explanation
Choice A rationale: An awake, alert, and crying newborn is a common observation and does not specifically indicate Neonatal Abstinence Syndrome (NAS). Newborns have varying sleep-wake cycles, and it’s normal for them to have periods of being awake and alert. Crying is also a normal behavior for newborns as it’s their primary means of communication. It could indicate a variety of needs such as hunger, the need for a diaper change, or just the need for comfort and contact. Therefore, while an excessively crying baby could potentially be a sign of discomfort or distress, it is
not specifically indicative of NAS.
Choice B rationale: The presence of acrocyanosis, which is the bluish color of the hands and feet, is a normal finding in the first 24 to 48 hours of life due to immature circulation. It’s not specifically associated with NAS. NAS is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Acrocyanosis is generally not a symptom of NAS.
Choice C rationale: A respiratory rate of 70/min is higher than the normal range (30-60/min) for a newborn and could indicate respiratory distress. However, it’s not specifically indicative of NAS. There are many potential causes of tachypnea (increased respiratory rate) in a newborn, including transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, meconium aspiration syndrome (MAS), and more. While infants with NAS mayexperience symptoms such as stuffy nose, sneezing, and rapid breathing, a high respiratory rate alone is not specifically indicative of NAS.
Choice D rationale: Jitteriness in the hands of a newborn can be a sign of Neonatal Abstinence Syndrome (NAS). NAS is a drug withdrawal syndrome in newborns that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction. Jitteriness or tremors, especially when disturbed, along with other signs such as high-pitched crying, poor feeding, and
loose stools, are more indicative of NAS.
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