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

"Baby powder will help prevent a diaper rash.”.

Choice A rationale:

"I will use mild soap”. indicates an appropriate understanding of newborn bathing. Mild soap is suitable for newborn skin to avoid irritation.

Choice B rationale:

This is the correct answer. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled and may lead to skin irritation. Therefore, the client needs further teaching about the use of baby powder.

Choice C rationale:

"I will test the water on my wrist for temperature before bathing”. demonstrates proper safety measures, ensuring the water is not too hot for the baby.

Choice D rationale:

"I will use a basin during bathing”. is a reasonable approach to bathing the newborn and does not indicate a need for further teaching.

A. Fetal circulation is no longer effective at birth. B. Fetal circulation continues until red blood cells are broken down. C. Fetal circulation continues until after the stress of labor. D. Fetal circulation continues until adulthood.

Correct Answer is C

Explanation

Fetal circulation continues until after the stress of labor.

Choice A rationale:

Fetal circulation undergoes significant changes at birth. It becomes ineffective as the transition from intrauterine to extrauterine life occurs. The foramen ovale and ductus arteriosus, which allow blood to bypass certain fetal circulatory pathways, close as the baby breathes for the first time.

Choice B rationale:

Fetal circulation does not continue until red blood cells are broken down. Red blood cells in a fetus have a shorter lifespan than those in adults and are continually replaced throughout gestation. However, their breakdown is not the reason for the changes in fetal circulation.

Choice C rationale:

The correct answer. Fetal circulation continues until after the stress of labor. During labor, the baby experiences increased stress and pressure, which helps trigger various physiological changes, including the closure of specific fetal circulatory shunts.

Choice D rationale:

Fetal circulation does not continue until adulthood. As mentioned earlier, the transition from fetal to adult circulation occurs during and after birth, with the closure of specific fetal shunts and the establishment of a fully functional adult circulatory 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

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?

Correct Answer is B

Explanation

Which statement about fetal circulation is true?

Correct Answer is C

Explanation

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