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","C","D"]

Explanation

Choice A: Warm the bottle in the microwave.

Rationale: Warming bottles in the microwave is not recommended. Microwaving can cause uneven heating, creating hot spots in the milk or formula that can burn the baby's mouth. Instead, bottles should be warmed by placing them in a container of warm water or using a bottle warmer.

Choice B: Store prepared bottles in the refrigerator.

Correct
Rationale: Prepared bottles of formula should be stored in the refrigerator to prevent bacterial growth. Formula should be used within 24 hours of preparation when properly stored in the refrigerator.

Choice C: Discard unused formula in used bottle after 2 hours.

Correct
Rationale: Any unused formula that has been in contact with the baby’s mouth should be discarded after 2 hours due to the risk of bacterial contamination. Bacteria from the baby's saliva can grow in the leftover formula.

Choice D: Never prop a bottle.

Correct
Rationale: Bottles should never be propped up and left in the baby’s mouth. This practice increases the risk of choking, ear infections, and tooth decay. Caregivers should always hold the bottle and the baby during feedings.

Choice E: Formula is available in three forms.

Correct
Rationale: Formula is available in three forms: powdered, concentrated liquid, and ready-to-feed. Parents should be informed of these options so they can choose the most convenient or appropriate form based on their needs.

A. The newborn with significant bruising from a face presentation. B. The premature newborn. C. The baby born at 41 weeks' gestation. D. The newborn with O+ blood type, born to a mother with O- blood type.

Correct Answer is C

Explanation

Choice A rationale:

(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.

Choice B rationale:

(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.

Choice C rationale:

(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.

Choice D rationale:

(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What should be included in teaching for bottle-feeding parents? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

Choice A: Warm the bottle in the microwave.

Choice B: Store prepared bottles in the refrigerator.

Choice C: Discard unused formula in used bottle after 2 hours.

Choice D: Never prop a bottle.

Choice E: Formula is available in three forms.

Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?

Correct Answer is C

Explanation

Which statement about fetal circulation is true?

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

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The nurse notes that a newborn's white blood cell count (WBC) is 15,000. The nurse is aware that:.

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