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 A

Explanation

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30

minutes old.

Choice B rationale

Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice C rationale

Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice D rationale

Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

A. Administer oxygen at 10 L/min via a nonrebreather mask B. Apply a fetal scalp electrode C. Change the client’s position D. Increase the rate of the IV infusion .

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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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 caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

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