A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?
Bilirubin 18 mg/dL.
Hemoglobin 22 g/dL.
Blood glucose 50 mg/dL.
Platelets 200,000/mm³.
The Correct Answer is A
Choice A rationale:
This is the priority finding because a bilirubin level of 18 mg/dL in a 4-hour-old newborn is significantly elevated. High bilirubin levels in newborns can lead to jaundice, which can be harmful if not promptly addressed. Hyperbilirubinemia in newborns requires close monitoring and, in some cases, treatment with phototherapy.
Choice B rationale:
A hemoglobin level of 22 g/dL is within the normal range for a newborn and is not a priority concern at this time.
Choice C rationale:
A blood glucose level of 50 mg/dL is within the normal range for a newborn. While monitoring blood glucose levels is essential, it is not the priority in this situation.
Choice D rationale:
A platelet count of 200,000/mm³ is within the normal range for a newborn and does not require immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
The newborn reflex called "rooting”. is characterized by turning the head and opening the mouth when the cheek or mouth area is touched. This reflex helps the newborn find the mother's breast for feeding.
Choice B rationale:
"Stepping”. is a newborn reflex where they make stepping movements when held upright with their feet touching a solid surface. This reflex is present at birth but tends to disappear after a few weeks.
Choice C rationale:
The "Moro”. reflex is also known as the startle reflex. It is elicited by a sudden loss of support or loud noise, causing the newborn to throw their arms and legs out and then bring them back in. This reflex usually disappears around 3 to 4 months of age.
Choice D rationale:
The "Babinski”. reflex is characterized by the extension of the big toe and fanning of the other toes when the sole of the foot is stroked. This reflex is present in newborns and should disappear by around 12 months of age.
Choice E rationale:
"Running”. is not a recognized newborn reflex. There is no reflex with this name related to newborns.
Choice F rationale:
The "gag”. reflex is present in newborns and helps protect the airway by causing a gagging response when the back of the throat is stimulated.
Correct Answer is B
Explanation
The nurse should first report the client's respiratory status to the primary health care.
Choice A rationale:
Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.
Choice B rationale:
Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.
Choice C rationale:
Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.
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