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.
The Correct Answer is A
A blood glucose fingerstick of 40 mg/dL for an infant who is 1- hour old.
Choice A rationale:
This finding should be notified to the charge nurse immediately because a blood glucose level of 40 mg/dL in a 1-hour-old infant is significantly lower than the normal range. Hypoglycemia in newborns can lead to serious complications, including neurological issues. Normal blood glucose levels in newborns are typically around 45-90 mg/dL.
Choice B rationale:
A hematocrit of 60% in an 8-hour-old infant may be considered relatively high, but this is a normal finding in newborns. Hematocrit levels can be higher in neonates due to their unique physiological adaptation to extrauterine life.
Choice C rationale:
Jaundice in a 4-hour-old infant is a common occurrence and is not typically a cause for immediate concern. Physiological jaundice often appears after 24 hours of birth and resolves on its own.
Choice D rationale:
Acrocyanosis, bluish discoloration of the hands and feet, is a normal finding in newborns and is not considered a cause for concern. It occurs due to the immature peripheral circulation and typically resolves within a few days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Washing the penis with warm water and mild soap each day is not an appropriate statement regarding circumcision care with a Plastibell device. Keeping the area clean is essential, but soap may irritate the wound, and frequent washing can disrupt the healing process.
Choice B rationale:
Ensuring a loose diaper in the front is not directly related to circumcision care with a Plastibell device. It may be relevant for comfort, but it does not address specific care for the circumcision site.
Choice C rationale:
This is a correct statement indicating understanding of circumcision care with the Plastibell device. The plastic ring is expected to fall off on its own within a week, and this is a normal part of the healing process.
Choice D rationale:
Applying petroleum jelly to the penis during diaper changes is not recommended for circumcision care with a Plastibell device. The petroleum jelly can interfere with wound healing and should be avoided.
Choice E rationale:
This is also a correct statement indicating understanding of circumcision care. If bleeding occurs after the Plastibell has fallen off, it could be a sign of a complication, and the doctor should be notified promptly.
Correct Answer is C
Explanation
Choice A rationale:
A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.
Choice B rationale:
A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.
Choice C rationale:
A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.
Choice D rationale:
A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.
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