A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?
Platelets 200,000/mm3
Bilirubin 19 mg/dL
Blood glucose 45 mg/dL
Hemoglobin 22 g/dL
The Correct Answer is B
- A) A platelet count of 200,000/mm3 is within the normal range for a newborn and does not require immediate intervention.
- B) A bilirubin level of 19 mg/dL is high and suggests the possibility of hyperbilirubinemia, which can lead to jaundice and, in severe cases, kernicterus, a form of brain damage. This is a critical value that requires immediate attention.
- C) A blood glucose level of 45 mg/dL is on the lower end of the normal range, but it is not as immediately concerning as the elevated bilirubin level. Monitoring and appropriate feeding should address this issue.
- D) A hemoglobin level of 22 g/dL is high, indicating polycythemia, which can be a risk factor for hyperviscosity syndrome. However, it is not as urgent as the bilirubin level of 19 mg/dL. Monitoring and partial exchange transfusion may be considered if symptoms develop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Molding refers to the shaping of the fetal head during labor and delivery to facilitate passage through the birth canal. It typically resolves within a few days and does not involve bruising.
B. Caput succedaneum is localized swelling or edema of the scalp that crosses suture lines and typically resolves within a few days. It is not associated with bruising.
C. Pilonidal dimple refers to a small pit or depression in the skin, typically at the base of the spine, and is not related to the finding described.
D. Cephalhematoma is a collection of blood between the skull bone and its periosteum. It is
confined by suture lines and may take weeks to resolve. It does not cross suture lines and may be associated with bruising due to birth trauma.
Correct Answer is A
Explanation
A. Changing the perineal pad is a task that can be safely delegated to an assistive personnel (AP) as it involves basic hygiene care and does not require nursing judgment.
B. Observing an area of redness on the breast may require nursing assessment and judgment to determine if further intervention is needed.
C. Monitoring vital signs during admission of a client with gestational hypertension requires nursing assessment and judgment to detect any signs of worsening condition or complications.
D. Providing a sitz bath to a client with a fourth-degree laceration requires nursing assessment and judgment to ensure appropriate wound care and pain management.
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