A nurse is caring for a newborn 8 hours of age.Which of the following assessment findings require follow-up by the nurse?

Large ecchymotic caput succedaneum noted on posterior scalp.

Yellow discoloration noted of sclera and oral mucosa.

Fontanel level and soft.

Respiratory rate 78/min.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.

Choice B rationale

Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.

Choice C rationale

A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.

Choice D rationale

A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.

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Correct Answer is C

Explanation

Choice A rationale

Docusate sodium is a stool softener and is not contraindicated for a postpartum client with a 4th degree laceration.

Choice B rationale

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can be safely used postpartum for pain management.

Choice C rationale

Carboprost is a medication used to control postpartum hemorrhage but is contraindicated in clients with asthma and with other risk factors due to its side effects, including severe diarrhea.

Choice D rationale

Ferrous sulfate is used to treat anemia and is not contraindicated in a postpartum client with a 4th degree laceration.

A. Evaluate glucose levels again in 4 hours. B. Assess for hypothermia. C. Notify MD on call. D. Evaluate blood serum glucose.

Correct Answer is C

Explanation

Choice A rationale

While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.

Choice B rationale

Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.

Choice C rationale

Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.

Choice D rationale

Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.

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A nurse is caring for a newborn 8 hours of age.Which of the following assessment findings require follow-up by the nurse?

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Naxlex Comprehensive Predictor Exams

The nurse develops a teaching plan for a 24-hour vaginal postpartum client with a firm fundus, scant lochia, and a 4th degree laceration.Her hemoglobin level is 10.0 gm/dl, and hematocrit is 30%. The mother is breastfeeding.Which medication would the nurse expect to be contraindicated?

Correct Answer is C

Explanation

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Explanation

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