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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F"]
Explanation
In the context of a client at 32 weeks of gestation with complete placenta previa, the following assessment findings require immediate follow-up:
A. Fetal heart rate:
Explanation: An elevated fetal heart rate (174/min) may be indicative of fetal distress. This finding requires immediate follow-up to assess the well-being of the fetus.
F. Vaginal bleeding:
Explanation: A moderate amount of bright red vaginal bleeding is a concerning sign, especially in the context of complete placenta previa. It indicates active bleeding, and immediate follow-up is necessary to assess the severity of the situation and the well-being of both the mother and the fetus.
C & D. Hemoglobin (Hgb) and Hematocrit (Hct):
Explanation: Hemoglobin and hematocrit levels are important indicators of blood loss. Given the vaginal bleeding, these values need immediate follow-up to assess the extent of maternal blood loss and the potential need for blood transfusion.
The following assessment findings do not require immediate follow-up in the given context:
B. Fundal height:
Explanation: Fundal height (33cm) is typically measured to assess fetal growth. While it's important to monitor, it may not be an immediate concern unless there are other signs of fetal distress.
E. Platelet count:
Explanation: While platelet count is important, it may not require immediate follow-up unless there is evidence of severe bleeding and a potential risk of disseminated intravascular coagulation (DIC). In this scenario, attention to Hgb and Hct is more urgent.
G & H. White Blood Cell (WBC) count and Red Blood Cell (RBC) count:
Explanation: WBC count and RBC count may be monitored but do not require immediate follow-up unless there are signs of infection or other complications not evident in the given information.
Correct Answer is A
Explanation
A. Fortified soy milk: Fortified soy milk is a good source of vitamin B12, which is important, especially for individuals following a vegan diet. Vitamin B12 is primarily found in animal products, so those on a vegan diet need to obtain it through fortified foods or supplements.
B. Brown rice: Brown rice is not a significant source of vitamin B12. While it contains other B vitamins, it lacks B12, which is vital for neurological health and the production of red blood cells.
C. Raw carrots: Carrots do not contain vitamin B12. They are rich in beta-carotene (a precursor to vitamin A) and provide other vitamins and minerals, but they are not a source of B12.
D. Fresh citrus fruits: Citrus fruits, like oranges and grapefruits, are good sources of vitamin C, but they do not contain vitamin B12. Vitamin C is important for the absorption of non-heme iron, which is found in plant-based foods, but it does not provide B12.
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