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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. The client will demonstrate proper bathing of the infant: This goal is more appropriate for later phases of postpartum adjustment when the mother becomes more involved in caring for her infant. During the taking-in phase, the focus is on the mother's own recovery.

B. The client will verbalize appropriate car seat safety: This goal is related to the safety and care of the newborn, and it may be more relevant in the taking-hold phase when the mother becomes more actively involved in caring for her baby.

C. The client will have adequate nutritional intake: This is the correct goal. Adequate nutritional intake is important for the mother's recovery, energy levels, and breastfeeding success. The nurse should assess and promote proper nutrition during the taking-in phase.

D. The client will identify individual family member roles: Family roles and dynamics are more commonly addressed in the postpartum adjustment phase known as the let-go phase, which occurs later as the mother becomes more comfortable and accepting of her new role.

A. Previous cervical cerclage B. Previous delivery at 37 weeks gestation C. Previous delivery of a newborn weighing 2.5 kg (5.5 lb) D. previous reactive non-stress test

Correct Answer is A

Explanation

A. Previous cervical cerclage

Cervical cerclage is a surgical procedure in which a stitch is placed in the cervix to reinforce it and reduce the risk of preterm birth. The fact that the client has had a previous cervical cerclage suggests a history of cervical insufficiency or a shortened cervix, which increases the risk of preterm delivery in subsequent pregnancies.

B. Previous delivery at 37 weeks gestation: A delivery at 37 weeks gestation is considered term. While it is on the earlier side of term, it does not inherently indicate an increased risk for preterm delivery.

C. Previous delivery of a newborn weighing 2.5 kg (5.5 lb): While low birth weight can be associated with preterm birth, the weight alone does not necessarily indicate a history of preterm delivery. Birth weight can be influenced by various factors.

D. Previous reactive non-stress test: A reactive non-stress test is a reassuring result, indicating that the fetus is responsive and generally doing well. It does not suggest a history or risk of preterm delivery.

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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 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