A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

Bilirubin 9 mg/dL

Hemoglobin 15 g/dL

Platelets 175.0000/mm3

Hematocrit 45%

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Bilirubin 9 mg/dL is correct. A bilirubin level of 9 mg/dL in a newborn, especially at 4 hours old, is elevated and needs prompt attention. High bilirubin levels in newborns can be indicative of jaundice, and severe jaundice may lead to complications such as kernicterus. Monitoring and managing bilirubin levels are crucial to prevent potential neurologic damage.

Choice B Reason:

Hemoglobin 15 g/dL is incorrect. This hemoglobin level is within the normal range for a newborn. It's important to note that newborns often have higher hemoglobin levels shortly after birth, and this value is consistent with normal physiological ranges.

Choice C Reason:

Platelets 175,000/mm³ is incorrect. A platelet count of 175,000/mm³ is within the normal range for a newborn. There is no immediate concern based on this platelet count.

Choice D Reason:

Hematocrit 45% is incorrect. A hematocrit level of 45% is within the normal range for a newborn. Like hemoglobin, hematocrit levels can be higher in newborns shortly after birth, and this value falls within the expected range.

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Correct Answer is B

Explanation

The correct answer is B. Massage the client's back.

A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.

B. Massage the client's back is consistent with the gate control theory of pain.

According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.

C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.

D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.

A. Pattern of contractions B. Station of the presenting part C. Changes in the cervix D. Rupture of the membrane

Correct Answer is C

Explanation

A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.

B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.

C. Changes in the cervix are a key sign of true labor.

True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.

D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.

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A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is B

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is C

Explanation

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