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 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.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
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