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 C

Explanation

A. weighing the newborn's wet diaper, is a routine part of newborn care but is not the first priority in this situation.
B. auscultating the newborn's bowel sounds, is important for assessing gastrointestinal function but is not the first priority when the baby is at risk for respiratory distress.
C. Neonatal abstinence syndrome (NAS) is a condition that occurs in newborns who were exposed to addictive substances in utero. One of the key concerns in NAS is respiratory distress, so determining the newborn's respiratory rate is the first priority.
D. swaddling the newborn in blankets, is a comfort measure but does not address the immediate concern of assessing respiratory status in a baby with suspected NAS.

A. Hyporeflexia B. Tachypnea C. Polyuria D. Agitation

Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

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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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Explanation

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Correct Answer is A

Explanation

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