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.
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Correct Answer is D
Explanation
A. This is not a primary consideration before bathing a newborn. The timing of the last feeding is more relevant to assessing the risk of hypoglycemia rather than determining readiness for a bath.
B. This temperature is slightly below the recommended range for newborns (36.5°C to 37.5°C). Bathing should be delayed until the newborn's temperature is stable.
C. While care of the umbilical cord is important, it does not determine the timing of the first bath. The cord can be kept dry even if the baby is bathed.
D. Ensuring that the newborn has maintained a stable body temperature for at least 2 hours is crucial before giving the first bath. Bathing can cause a drop in body temperature, so it's essential that the newborn's thermoregulation is stable to avoid hypothermia.
Correct Answer is D
Explanation
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
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