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 A
Explanation
Hypotension is a common complication associated with epidural anesthesia in labor. When the epidural anesthesia is administered, it can cause vasodilation, which can lead to a decrease in blood pressure. This decrease in blood pressure can result in hypotension. Measures such as administering intravenous fluids and positioning the client on her left side can help mitigate this complication. Vomiting, tachycardia, and respiratory depression are less common complications associated with epidural anesthesia in labor.
Correct Answer is D
Explanation
A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.
B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+-4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.