A nurse is collecting data from a newborn who was born 2 hr ago. Which of the following findings should the nurse report to the provider?
Overlapping suture lines
Acrocyanosis
Hypotonia
Blood glucose level 40 mg/dL
The Correct Answer is D
A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Monitoring for infection is an appropriate nursing intervention for a client whose membranes have ruptured, as there is an increased risk of infection after the amniotic sac has ruptured for an extended period.
B) Incorrect- Positioning the client supine is not generally recommended for a client in labor, especially if the client's membranes have ruptured.
C) Incorrect- Obtaining consent for a cesarean birth is not indicated solely based on the information provided.
D) Incorrect- Preparing for a forceps delivery is not indicated solely based on the information provided.
Correct Answer is C
Explanation
A) Incorrect- Hydrocortisone ointment is not typically recommended for treating mastitis, as it might not address the underlying infection.
B) Incorrect- Wearing a well-fitting, supportive nursing bra can actually help alleviate discomfort and is not typically contraindicated in cases of mastitis.
C) Correct - Applying warm compresses to the affected breast can help reduce pain and discomfort associated with mastitis. Warmth can improve blood flow and promote milk flow.
D) Incorrect- Encouraging the client to limit oral fluid intake to decrease milk production is not a recommended approach, as maintaining proper hydration is important, especially when dealing with infection.
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