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 A
Explanation
A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
Correct Answer is B
Explanation
A. Educating the parents about the defect is important for their understanding and involvement in the care of the newborn, but it is not the priority when the infant has a myelomeningocele.
B. Maintaining the integrity of the sac is the priority goal in the care of a newborn with myelomeningocele to prevent infection and protect the exposed neural tissue.
C. Providing age-appropriate stimulation is important for the overall development of the newborn but is not the priority when the infant has a myelomeningocele.
D. Promoting maternal-infant bonding is essential for the emotional well-being of both the
mother and the newborn, but it is not the priority when immediate physical care needs exist, such as maintaining the integrity of the sac.
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