A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.
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
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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Related Questions
Correct Answer is D
Explanation
A. "You cannot have an amniocentesis until you are at least 35 years of age": This statement is not accurate. While advanced maternal age (35 years or older) is often a factor considered for offering amniocentesis due to the increased risk of chromosomal abnormalities, it is not the only factor. Amniocentesis may be recommended for various medical reasons, such as a history of genetic disorders or abnormal prenatal screening results.
B. "We can schedule the procedure for later today if you'd like": The decision to undergo amniocentesis should not be made lightly, and it is typically based on medical indications or concerns. Immediate scheduling without a medical reason is not appropriate. Informed consent and discussion with the healthcare provider about the risks and benefits of the procedure are essential.
C. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby": Chorionic villus sampling (CVS) is a different prenatal diagnostic procedure used to obtain a small sample of placental tissue for genetic testing. It is not typically used solely for determining the sex of the baby. Amniocentesis is the procedure commonly used for both genetic testing and determining the sex of the fetus.
D. "This procedure determines if your baby has genetic or congenital disorders": This is the most appropriate response. Amniocentesis is a diagnostic procedure that involves the removal of a small amount of amniotic fluid for analysis. It is commonly used to assess the risk of genetic and congenital disorders, including chromosomal abnormalities.
Correct Answer is B
Explanation
A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.
B. I should avoid becoming pregnant for at least 1 month following the immunization
Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.
C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.
D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.
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