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 C

Explanation

Choice A rationale:

Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.

Choice B rationale:

Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.

Choice C rationale:

Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.

A. Dry the baby thoroughly. B. Suctioning the mouth and nose with a bulb syringe to clear mucus. C. Observe the chest and abdomen. D. Count the number of respirations per minute.

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

Explanation

Choice A rationale:

Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.

Choice B rationale:

Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.

Choice C rationale:

Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.

Choice D rationale:

Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.

Choice E rationale:

Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.

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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

Correct Answer is C

Explanation

Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

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

Explanation

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?

The purpose of surfactant is to?

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

A nurse is reinforcing teaching with a parent about using an iron-fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?

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The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. What is the nurse's priority action?

A nurse is reinforcing teaching with a client who is postpartum about bathing her newborn. Which of the following statements by the client indicates a need for further teaching?

Which statement about fetal circulation is true?