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. Hypertension: Hypertension is not typically associated with abruptio placentae. In fact, abruptio placentae is often linked to conditions such as chronic hypertension, but the presentation is more commonly associated with symptoms like uterine tenderness, bleeding, and fetal distress.
B. Uterine tenderness: This is the correct answer. Uterine tenderness is a common clinical finding in abruptio placentae. It results from the separation of the placenta from the uterine wall, leading to blood accumulation in the uterine musculature.
C. Leukorrhea: Leukorrhea, a white or yellowish discharge from the vagina, is not a typical finding in abruptio placentae. The condition is characterized by vaginal bleeding and uterine tenderness.
D. Fetal tachycardia: Fetal distress, including fetal tachycardia, is a potential complication of abruptio placentae. However, uterine tenderness is a more immediate and direct finding associated with the separation of the placenta.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today