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 B
Explanation
Choice A rationale
Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice B rationale
Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice D rationale
Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Correct Answer is C
Explanation
The correct answer is Choice C. . . However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
Choice B rationale
Applying a fetal scalp electrode is a procedure used for continuous fetal heart monitoring during labor. It provides a more accurate and consistent transmission of the fetal heart rate than external methods. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
Choice C rationale
Changing the client’s position can help improve uteroplacental blood flow and fetal oxygenation. It is often the first action taken when late decelerations are noted in the FHR.
Choice D rationale
Increasing the rate of the IV infusion can help increase maternal blood volume and improve uteroplacental blood flow. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.
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