A nurse is caring for a newborn 8 hours of age
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
53. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, most commonly in the fallopian tube. One of the hallmark symptoms of an ectopic pregnancy is unilateral, cramp-like abdominal pain depending on the location of the pregnancy.
A. Uterine enlargement greater than expected for gestational age is not expected in an ectopic pregnancy because the fertilized egg implants outside the uterus, so there is no uterine enlargement.
C. Severe nausea and vomiting are more commonly associated with conditions such as hyperemesis gravidarum or early pregnancy symptoms but are not specific to ectopic pregnancy.
D. A large amount of vaginal bleeding may occur in some cases of ectopic pregnancy, but it is not a consistent or defining characteristic.
Correct Answer is D
Explanation
A fetal heart rate of 158/min is within the normal range for a fetus.
B. Respirations of 16/min are within the normal range for an adult.
C. Headache can be a symptom of pre-eclampsia, but it does not necessarily indicate magnesium toxicity.
D. Decreased urinary output can indicate renal insufficiency or impaired kidney function, which can be a sign of magnesium toxicity.
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