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 ["The medical term for the soft spot on a baby's skull is fontanelle (or fontanel)."]
Explanation
The medical term for the soft spot on a baby's skull is fontanelle (or fontanel). Fontanelles are gaps between the bones of the skull that allow for the baby's brain to grow and accommodate rapid brain development during infancy. There are typically two fontanelles in a newborn's skull: the anterior fontanelle (located at the top/front of the head) and the posterior fontanelle (located at the back of the head). These fontanelles are composed of connective tissue and remain open during the early months of life, gradually closing as the baby's skull bones fuse together over time. Healthcare professionals often assess fontanelles during routine physical exams of infants. The fontanelle's size and tension can provide valuable information about the baby's hydration status, intracranial pressure, and neurological development.
Normally, the fontanelles should feel relatively soft and flat, indicating proper hydration and brain development. If the fontanelles are sunken or overly tense, it may suggest dehydration or increased intracranial pressure, which requires further evaluation and management. The proper examination of fontanelles is an essential part of newborn care, and any abnormalities observed during assessment should be promptly reported to the healthcare provider for appropriate evaluation and intervention.
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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