A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Weight loss of 3%

Voided one time since birth

Central cyanosis

Apical pulse rate of 156/min

Answer and Explanation

The Correct Answer is C

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The client will verbalize appropriate car seat safety.

Teaching about car seat safety is important for the mother's understanding of infant care, but it is not specifically related to the taking-in phase, which primarily focuses on the mother's adjustment and recovery.

B. The client will demonstrate proper bathing of the infant.

Similarly, teaching about infant care, such as proper bathing techniques, is important but may be more appropriate for later phases of postpartum adjustment when the mother is more focused on caring for her infant.

C. The client will identify individual family member roles.

This goal may be more relevant to later phases of postpartum adjustment when the mother begins to integrate the new baby into the family unit. During the taking-in phase, the focus is primarily on the mother's own adjustment.

D. The client will have adequate nutritional intake.

This goal aligns with the priorities of the taking-in phase, which include the mother's physical recovery and well-being. Adequate nutritional intake is essential for postpartum recovery and breastfeeding, making it an appropriate goal for this phase.

A. Administer oxygen via face mask at 10 L/min. B. Collect hemoglobin and hematocrit levels. C. Prepare the client to receive a plasma expander. D. Insert an indwelling urinary catheter.

Correct Answer is B

Explanation

A. Administer oxygen via face mask at 10 L/min:

Administering oxygen can help improve tissue oxygenation and prevent hypoxia, which is critical in managing a client at risk of hypovolemic shock. However, while oxygenation is important, it may not directly address the underlying cause of the excessive bleeding. Therefore, while oxygen may be necessary, it is not the most immediate action required to address the potential cause of the hemorrhage.

B. Collect hemoglobin and hematocrit levels:

Collecting hemoglobin and hematocrit levels is essential for assessing the extent of blood loss and the client's hemodynamic status. This information will help determine the severity of the situation and guide further management and interventions, such as blood transfusion if indicated. Since postpartum hemorrhage is a leading cause of maternal mortality, prompt assessment of blood loss is crucial in guiding appropriate interventions to prevent further complications.

C. Prepare the client to receive a plasma expander:

Plasma expanders may be administered to help restore circulating blood volume in cases of hypovolemic shock due to significant blood loss. However, before initiating plasma expander administration, it is essential to assess the client's hemoglobin and hematocrit levels to determine the severity of blood loss and guide appropriate fluid resuscitation strategies. Therefore, preparing the client to receive a plasma expander would come after assessing the extent of blood loss through laboratory values.

D. Insert an indwelling urinary catheter:

Inserting an indwelling urinary catheter may be necessary to monitor urinary output, which is an important indicator of renal perfusion and overall fluid status. However, while urinary catheterization is important for assessing renal function and fluid balance, it is not the most immediate action required to address the potential cause of the hemorrhage. Assessing blood loss through laboratory values and initiating appropriate interventions to manage postpartum hemorrhage take precedence over urinary catheterization in this scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?

Correct Answer is D

Explanation

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old. Exhibits Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.