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 B
Explanation
A. Fetal heart rate 152/min: Fetal heart rate is not typically considered an adverse effect of epidural analgesia. The focus of epidural analgesia is on providing pain relief for the mother rather than directly affecting the fetal heart rate.
B. Hypotension: Hypotension (low blood pressure) is a common adverse effect of epidural analgesia. Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. The nurse should monitor the client's blood pressure closely and administer interventions as needed, such as IV fluids or medications to address hypotension.
C. Polyuria: Polyuria (excessive urination) is not a direct adverse effect of epidural analgesia. Epidural analgesia primarily affects pain sensation rather than urinary function.
D. Maternal temperature of 37.4 C (99.4 F): A slightly elevated maternal temperature is not a common adverse effect of epidural analgesia. However, the nurse should monitor for signs of infection or other complications and report any significant temperature changes to the healthcare provider.
Correct Answer is A
Explanation
A. Use fingers to exert upward pressure on the presenting part
The priority in the case of a prolapsed umbilical cord is to relieve pressure on the cord to maintain blood flow to the fetus. The nurse should use sterile-gloved fingers to lift the presenting part of the fetus off the prolapsed cord. This action helps prevent compression of the umbilical cord, which could lead to fetal hypoxia and distress.
B. Administer a tocolytic medication: Tocolytic medications are used to inhibit uterine contractions. While tocolytics might be used in certain situations, the immediate concern with a prolapsed cord is to relieve pressure on it to maintain fetal blood flow.
C. Wrap the cord in a sterile towel and moisten with warm sterile normal saline: While covering the cord with a sterile towel and moistening it can help prevent drying and protect the cord, it is not the first priority. The primary concern is relieving pressure on the cord to prevent fetal compromise.
D. Apply oxygen via facemask to the client: Oxygen administration is important in managing fetal distress, but it is not the first action to take in the case of a prolapsed umbilical cord. The priority is to relieve pressure on the cord to maintain fetal oxygenation.
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