A nurse is caring for a newborn immediately following birth.

Exhibits

The nurse is assessing the newborn 24 hr later.

How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Findings 24 hr later:

Color: Consistent with genetic background.

Axillary temperature 36.3° C (97.4°F). Reflex irritability: cry.

Muscle tone: flaccid.

Respiration effort: good cry.

Heart rate 140/min.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Nursing Test Bank

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Free Nursing Study Resources

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

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

A. Blood pressure 88/40 mm Hg. B. Urinary output 40 mL/hr. C. Moderate rubra lochia. D. Heart rate 90/min.

Correct Answer is A

Explanation

Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.).

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

Explanation

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

A nurse is caring for a client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?