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.
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Related Questions
Correct Answer is B
Explanation
The nurse should first report the client's respiratory status to the primary health care.
Choice A rationale:
Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.
Choice B rationale:
Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.
Choice C rationale:
Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.
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.
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