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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Increase the oxytocin infusion to 13 mu/min:

Anticipated: This action is anticipated. Adjusting the oxytocin infusion rate may be appropriate based on the progress of labor and the response to the current infusion rate.

Place client in a side-lying position:

Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

Initiate a bolus of primary IV fluids:

Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.

Apply oxygen at 10 L/Min via a venturi mask:

Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.

Perform sterile vaginal examination (SVE):

Contraindicated: There is no indication for a sterile vaginal examination (SVE) at this time based on the information provided. Frequent unnecessary SVEs can increase the risk of infection.

Assign a Bishop score:

Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed during admission, and the current focus is on monitoring the progress of labor with oxytocin.

Perform an amniotomy:

Anticipated: Depending on the clinical situation, performing an amniotomy (artificial rupture of membranes) may be anticipated as part of the labor induction process. However, the decision should be based on the overall assessment and progress of labor.

A. Increase the rate of maintenance IV infusion. B. Place the client in the lateral position C. Elevate the client's legs D. Administer oxygen using a nonrebreather mask

Correct Answer is B

Explanation

The correct answer is B. Place the client in the lateral position.

A. Increasing the rate of maintenance IV infusion may be necessary, but the initial action should be to address potential aortocaval compression. Repositioning the client to the lateral position helps alleviate compression on the vena cava and improves blood flow to the uterus.

B. Placing the client in the lateral position is the correct first action. Changing the client's position, particularly from a supine to a side-lying position, can relieve aortocaval compression and improve uteroplacental perfusion.

C. Elevating the client's legs is not the priority in this situation. Repositioning the client to the lateral position is more important to address potential aortocaval compression.

D. Administering oxygen using a nonrebreather mask may be indicated, but repositioning the client to the lateral position is the first action to address potential aortocaval compression. Oxygen administration can follow if necessary.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Correct Answer is B

Explanation

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