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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
The newborn reflex called "rooting”. is characterized by turning the head and opening the mouth when the cheek or mouth area is touched. This reflex helps the newborn find the mother's breast for feeding.
Choice B rationale:
"Stepping”. is a newborn reflex where they make stepping movements when held upright with their feet touching a solid surface. This reflex is present at birth but tends to disappear after a few weeks.
Choice C rationale:
The "Moro”. reflex is also known as the startle reflex. It is elicited by a sudden loss of support or loud noise, causing the newborn to throw their arms and legs out and then bring them back in. This reflex usually disappears around 3 to 4 months of age.
Choice D rationale:
The "Babinski”. reflex is characterized by the extension of the big toe and fanning of the other toes when the sole of the foot is stroked. This reflex is present in newborns and should disappear by around 12 months of age.
Choice E rationale:
"Running”. is not a recognized newborn reflex. There is no reflex with this name related to newborns.
Choice F rationale:
The "gag”. reflex is present in newborns and helps protect the airway by causing a gagging response when the back of the throat is stimulated.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
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