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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.

Exhibits

Which of the following findings should the nurse report to the provider?

Select all that apply

Coombs test result

Glucose level

Head assessment finding

Intake and output

Respiratory rate

Heart rate

Mucous membrane assessment

Sclera color

Answer and Explanation

Correct Answer : A,D,G,H

In the context of the newborn's information, the nurse should report the following findings to the provider:

A. Coombs test result:

Explanation: The Coombs test checks for the presence of antibodies that can destroy red blood cells. In the absence of information about any specific concern or risk factors, a Coombs test result may not be immediately necessary for a term newborn. The nurse should report this finding to the provider for clarification on why the test was performed.

D. Intake and output:

Explanation: The newborn has voided only once since birth. Infrequent voiding can be a concern, and the nurse should report this to the provider for further evaluation, as adequate urine output is important to assess renal function and hydration status.

G. Mucous membrane assessment:

Explanation: Mucous membrane color and moisture are important indicators of hydration. If there are abnormalities, such as pale or dry mucous membranes, the nurse should report this to the provider for further assessment.

H. Sclera color:

Explanation: The color of the sclera can indicate jaundice in a newborn. If the sclera color appears yellow or jaundiced, the nurse should report this finding to the provider for further evaluation.

The following findings are not typically of immediate concern in the given context:

B. Glucose level:

Explanation: While glucose levels are important in certain situations, there is no information suggesting a need for immediate concern about glucose levels in this case. The nurse can monitor blood glucose levels as part of routine care but does not need to report it without specific concerns.

C. Head assessment finding:

Explanation: The information does not provide details about any abnormal head assessment findings. If there are no specific concerns mentioned, the nurse may not need to report this finding unless there are abnormalities observed during routine assessments.

E. Respiratory rate:

Explanation: The respiratory rate is not highlighted as a concern in the given information. If there are no specific abnormalities or signs of respiratory distress, the nurse may not need to report this finding without additional information.

F. Heart rate:

Explanation: The heart rate is not highlighted as a concern, and a normal Apgar score was noted at 5 minutes. If there are no specific concerns or abnormal findings related to the heart rate, the nurse may not need to report this finding without additional information.

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Correct Answer is D

Explanation

A. Applying hydrating lotion to the newborn's skin prior to treatment is not recommended as lotions or creams can interfere with the effectiveness of phototherapy and may increase the risk of skin irritation or burns.

B. Turning the newborn every 4 hours is insufficient; the newborn should be turned more frequently, typically every 2 hours, to ensure even exposure to the phototherapy light and to prevent pressure sores.

C. Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation.

D. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.

A. apply a vaginal lubricant to the diaphragm prior to insertion B. insert the diaphragm up to 6 hr before intercourse C. Remove the diaphragm 2 to 4 hr after intercourse D. Wash diaphragm with soap between uses

Correct Answer is B

Explanation

a: The diaphragm should be used with a spermicide, not a vaginal lubricant. Spermicide is necessary to kill sperm and increase the effectiveness of the diaphragm.

b: The diaphragm can be inserted up to 6 hours before intercourse, making it a convenient option for contraception. It should be left in place for at least 6 hours after intercourse but not more than 24 hours to ensure effectiveness.

c: The diaphragm should not be removed 2 to 4 hours after intercourse. It must remain in place for at least 6 hours after intercourse to provide effective contraception.

d:Washing the diaphragm with detergent soap can damage the latex and increase the risk of deterioration. It should be washed with mild soap and water or with a special cleanser recommended by the healthcare provider.

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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old. Exhibits Which of the following findings should the nurse report to the provider? Select all that apply

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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.

Exhibits

Which of the following findings should the nurse report to the provider?

Select all that apply