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

Answer and Explanation

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.

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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.

A. "Place the retainer clip across the newborn's abdomen." B. "Keep the car seat rear-facing until the newborn can sit unsupported." C. "Position the newborn at a 45-degree angle in the car seat." D. "Place the shoulder harness straps below the level of the newborn's armpits."

Correct Answer is C

Explanation

a. "Place the retainer clip across the newborn's abdomen":

This statement is incorrect and potentially dangerous. The retainer clip should be positioned at the level of the armpits to secure the harness straps. Placing it across the abdomen could cause abdominal injury in the event of sudden braking or a crash.

b. "Keep the car seat rear-facing until the newborn can sit unsupported":

While this is generally true and important safety advice, it is not directly related to the positioning of the newborn in the car seat. Instead, it addresses the orientation of the car seat itself. Rear-facing car seats are safer for infants as they provide better protection for the head, neck, and spine in the event of a crash.

c. "Position the newborn at a 45-degree angle in the car seat":

This is the correct recommendation. Newborns should be positioned at a 45-degree angle in the car seat to prevent their head from falling forward and potentially obstructing their airway. Many car seats come with angle adjusters or indicators to help achieve this optimal positioning.

d. "Place the shoulder harness straps below the level of the newborn's armpits":

Placing the shoulder harness straps below the level of the newborn's armpits is incorrect. The straps should be positioned at or slightly below the level of the shoulders to provide proper restraint. Placing them too low increases the risk of the baby slipping out of the harness in the event of a crash.

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A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is B

Explanation

A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client 2 hours after a spontaneous vaginal birth, and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

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A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?