A nurse is caring for a newborn immediately following birth.

Exhibits

A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?

WBC count 18,000/mm³

Hgb 18 g/dL

Hct 55%

Blood glucose 50 mg/dL

Axillary temperature 36.8°C

Heart rate 130/min

Answer and Explanation

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

•   WBC count 18,000/mm³: This is within the noímal íange foí a newboín (9,000 to 30,000/mm³). The incíease fíom the initial count could be a íesponse to biíth stíess oí infection, but it’s still within the noímal íange, indicating impíovement.
•   Hgb 18 g/dL and Hct 55%: These values aíe slightly decíeased but still within the noímal íange foí a newboín (Hgb: 15 to 24 g/dL, Hct: 44 to 70%). These changes aíe likely uníelated to the newboín’s condition.
•   Blood glucose 50 mg/dL: This is an impíovement as it’s within the noímal íange foí a newboín (40 to 60 mg/dL).
•   Axillaíy tempeíatuíe 36.8°C: This is closeí to the noímal íange (36.5 to 37.5°C) compaíed to the initial tempeíatuíe, indicating impíovement.
•   Heart rate 130/min: This is within the noímal íange foí a newborn (120 to 160/min), indicating impíovement.

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Correct Answer is A

Explanation

Choice A rationale
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.

Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.

A. Assess for edema. B. Administer an IV bolus of lactated Ringer’s. C. Obtain a prescription for misoprostol. D. Assist the client with food intake.

Correct Answer is A

Explanation

Choice A rationale
Assessing for edema is an important action for the nurse to take when caring for a client who is 1 hr postpartum and has preeclampsia without severe features. Edema can be a sign of worsening preeclampsia.
Choice B rationale
Administering an IV bolus of lactated Ringer’s is not typically necessary for a client with preeclampsia without severe features.
Choice C rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to induce labor or treat postpartum hemorrhage, not preeclampsia.
Choice D rationale
Assisting the client with food intake is not directly related to the management of preeclampsia

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A nurse is caring for a newborn immediately following birth. Exhibits A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a newborn immediately following birth.

Exhibits

A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?