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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.

Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.

Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.

Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.

A. Monitor axillary temperature. B. Monitor weight. C. Monitor blood glucose levels. D. Provide age-appropriate stimulation.

Correct Answer is C

Explanation

Choice A rationale

Monitoring axillary temperature is important for all newborns to prevent hypothermia. However, it is not the priority intervention for a newborn who is small for gestational age (SGA). These newborns are at a higher risk for hypoglycemia due to decreased stores of glycogen and a lower rate of gluconeogenesis.

Choice B rationale

Monitoring weight is important for all infants, and ongoing monitoring is important for infants who are SGA. However, it is not the priority intervention for this client at this time.

Choice C rationale

This is the correct answer. Newborns who are SGA are at a higher risk for hypoglycemia. Therefore, monitoring of blood glucose levels is a priority intervention.

Choice D rationale

Providing age-appropriate stimulation is important for all newborns. However, it is not the priority intervention for a newborn who is SGA2.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia. Which of the following observations should the nurse immediately report to the healthcare provider?

Correct Answer is C

Explanation

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

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