A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old.

A hematocrit of 60% in an infant who is 8-hr old.

Jaundice in an infant who is 4-hr old.

Acrocyanosis in an infant who is 2-hr old.

Answer and Explanation

The Correct Answer is C

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.

B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion

C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.

D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.

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Correct Answer is B

Explanation

Choice A rationale:

Pseudomenstration is a normal finding in newborn females due to the withdrawal of maternal hormones. It is not a cause for concern and typically resolves within a few days after birth.

Choice B rationale:

Positive Ortolan's test is a concerning finding in a newborn and indicates the possibility of developmental dysplasia of the hip (DDH). This test is used to check for hip instability, and a positive result may warrant further evaluation and intervention to prevent long-term hip problems.

Choice C rationale:

Dermal melanosis, also known as Mongolian spots, is a common benign condition in newborns with dark skin. It appears as blue or gray patches and typically fades within the first few years of life. While it may be alarming to parents, it is not a cause for immediate concern.

Choice D rationale:

Gynecomastia, the enlargement of breast tissue in male infants, is relatively common and is caused by the transfer of maternal hormones during pregnancy. It usually resolves on its own within a few weeks and does not pose a significant health risk.

A. Activate respiratory arrest procedures. B. Request an order for supplemental oxygen. C. Continue routine monitoring. D. Report the observation to the charge nurse immediately.

Correct Answer is C

Explanation

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.

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A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

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Naxlex Comprehensive Predictor Exams

The nurse is most concerned about which assessment finding?

Correct Answer is B

Explanation

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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