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 are the 5 findings the nurse should 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

Choice A rationale

Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.

Choice B rationale

While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.

Choice C rationale

Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.

Choice D rationale

Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.

A. Cerebral manifestations. B. Gastrointestinal assessment findings. C. Respiratory rate. D. Deep tendon reflexes.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.

Choice B rationale

Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.

Choice C rationale

Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.

Choice D rationale

Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.

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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 4 hours old. After reviewing the information in the newborn’s medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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