A nurse is caring for a newborn 8 hours of age

exhibits

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1°C (97°F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosal Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted. Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min

Axillary temperature 36.1°C (97°F)

Respiratory rate 78/min

Nasal flaring present

Blood-tinged mucus noted at the vaginal opening

Uric acid crystals observed in the urine

Breastfed x 1 in the past 6 hr for 10 min.

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

The temperature is slightly lower than the normal range for a newborn (which is typically around 36.5-37.5°C or 97.7-99.5°F), indicating potential hypothermia. This requires follow-up to ensure appropriate warmth and to monitor for any signs of infection.

The neonates heart rate is within the normal range

The respiratory rate is slightly elevated. This may indicate respiratory distress or another respiratory issue that requires further evaluation.

Yellow discoloration noted of sclera and oral mucosa: This could be indicative of jaundice, a common condition in newborns.

Nasal flaring can be a sign of respiratory distress and requires further assessment to determine the cause and appropriate management.

Blood-tinged mucus noted at the vaginal opening could indicate trauma or another issue related to delivery and should be evaluated to ensure there are no complications.

Uric acid crystals may also indicate dehydration or other metabolic issues that require further evaluation.

Newborns should breastfeed more often failure to which may indicate a problem in the sucking or sepsis.

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Correct Answer is D

Explanation

If the mother is Rh-negative and the fetus is Rh-positive, the mother may produce anti-Rh antibodies, which can cross the placenta and cause hemolysis of the fetal red blood cells, leading to hyperbilirubinemia in the newborn.

A. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding B. A client who has missed a period and reports vaginal spotting C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who is at 38 weeks of gestation and reports a cough and fever

Correct Answer is A

Explanation

Painless vaginal bleeding in the third trimester could be a sign of placenta previa or placental abruption, both of which are serious conditions requiring immediate medical attention. This client should be seen first due to the potential urgency of the situation.
B. Vaginal spotting in early pregnancy may indicate implantation bleeding or other benign causes, but it could also be a sign of threatened miscarriage or ectopic pregnancy. While this client needs assessment, it's not as urgent as antepartum hemorrhage.
C. A client who is at 14 weeks of gestation and reports nausea and vomiting:

Nausea and vomiting are common symptoms in early pregnancy and typically do not require urgent intervention unless severe dehydration or hyperemesis gravidarum is present.
D. A cough and fever in late pregnancy may indicate a respiratory infection or another illness, but it does not pose an immediate threat to maternal or fetal health.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is D

Explanation

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Correct Answer is A

Explanation

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