A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

Positive Moro reflex

Erythema toxicum

Acrocyanosis

Elevated bilirubin level

Answer and Explanation

The Correct Answer is D

A.   a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B.   erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C.   acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D.   an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.

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Correct Answer is A

Explanation

A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.

A. TENS eliminates pain during a contraction. B. TENS is contraindicated for clients who have gestational diabetes. C. TENS intensity is manually increased during a contraction. D. TENS is most useful during the third stage of labor.

Correct Answer is C

Explanation

A. TENS provides pain relief but does not eliminate pain completely during contractions.
B. TENS is not contraindicated for clients with gestational diabetes unless there are specific medical concerns related to its use.
C. TENS intensity should be increased during contractions to provide additional pain relief.
D. TENS can be useful throughout labor, not just during the third stage.

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A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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