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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale
Maternal cytomegalovirus (CMV) infection is a serious health concern as it is associated with severe birth defects like sensori-neural hearing loss, impairment of cognitive development, and cerebral palsy. It is acquired by contact with body fluids and by vertical transmission from mother to fetus. Transmission can occur via the saliva and urine of the newborn, which is why this is the correct answer.
Choice B rationale
CMV does not require airborne precautions. It is not an airborne disease; it is spread through close, direct contact with a person infected with the virus.
Choice C rationale
CMV does not cause visible lesions on the mother’s genitalia. This is a characteristic of other sexually transmitted infections, not CMV2.
Choice D rationale
Mothers do not receive prophylactic treatment with acyclovir prior to delivery to prevent CMV2. Acyclovir is an antiviral medication used to treat herpes simplex virus infections, not CMV2.

A. Regurgitation B. Transient strabismus C. Mottling D. Respiratory rate 70/min E. Continuous high-pitched cry

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

Explanation

• Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
• Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
• Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
• Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
• Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
• Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.

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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 manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. What information should the nurse manager include in the teaching?

Correct Answer is A

Explanation

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

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?