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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 C

Explanation

A. Three fetal movements perceived by the client in a 20-min testing period: Perceiving fetal movements during the testing period is a positive finding and indicative of fetal well-being.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period: This is considered a reassuring result in an NST, showing an appropriate acceleration in the fetal heart rate in response to fetal movement, which is a normal and positive finding.

C. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client

During a nonstress test (NST), the presence of uterine contractions can sometimes interfere with the interpretation of fetal heart rate (FHR) patterns. If contractions occur but are not felt by the client, it can affect the accuracy of the test. Therefore, irregular contractions that are not felt by the client may prompt the need for further evaluation or testing to ensure accurate assessment of fetal well-being.

D. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period: Absence of late decelerations during uterine contractions is also a reassuring finding, indicating that the baby is tolerating the stress of contractions well.

A. Cloudy urine B. Fundus at level of umbilicus C. Blood pressure 80/50 mm Hg D. Moderate lochia rubra E. Fundus firm to palpation F. Thready pulse

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

Explanation

Cloudy urine:

Interpretation: Sign of potential improvement

Explanation: Cloudy urine is unrelated to the diagnosis of postpartum hemorrhage. However, it may be a sign of dehydration, and if the client is receiving appropriate interventions, improved hydration may lead to clearer urine.

Fundus at the level of the umbilicus:

Interpretation: Sign of potential worsening condition

Explanation: The fundus at the level of the umbilicus suggests that the uterus is not adequately contracting. This finding is a sign of potential worsening condition as the uterus should be contracting and descending in the postpartum period.

Blood pressure 80/50 mm Hg:

Interpretation: Sign of potential worsening condition

Explanation: A significant drop in blood pressure (80/50 mm Hg) is indicative of hypotension, which can be a sign of worsening postpartum hemorrhage. Hypotension requires immediate attention and intervention.

Moderate lochia rubra:

Interpretation: Unrelated to diagnosis

Explanation: Lochia rubra is the normal vaginal discharge after childbirth and is unrelated to the diagnosis of postpartum hemorrhage. It is a normal part of the postpartum recovery process.

Fundus firm to palpation:

Interpretation: Sign of potential improvement

Explanation: A firm fundus to palpation is a positive sign, indicating that the uterus is contracting and the bleeding may be decreasing. This is a sign of potential improvement.

Thready pulse:

Interpretation: Sign of potential worsening condition

Explanation: A thready pulse is indicative of reduced cardiac output, possibly due to significant blood loss. It is a sign of potential worsening condition and requires prompt intervention.

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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 assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is C

Explanation

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

Explanation

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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