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.

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Correct Answer is A

Explanation

A.Dry mucous membranes may indicate dehydration. The newborn is breastfeeding only 3–4 times per day, which is lower than the recommended 8–12 feedings per day for adequate hydration and nutrition.

B.Yellow sclera suggests jaundice, which could indicate neonatal hyperbilirubinemia. Since the newborn is Coombs-positive, there is an increased risk of hemolytic disease of the newborn (HDN) due to blood incompatibility, making bilirubin monitoring essential.

D.The newborn has voided only once in 36 hours, which may indicate dehydration or inadequate fluid intake. Additionally, the absence of a meconium stool may suggest intestinal obstruction, delayed passage, or meconium plug syndrome, requiring further evaluation.

E.A positive Coombs test means that maternal antibodies have attacked the newborn’s red blood cells, increasing the risk of hemolytic anemia and jaundice. This finding correlates with the yellow sclera, necessitating further bilirubin monitoring.

Incorrect answers:

C.Caput succedaneum is benign and self-resolving. It is a soft tissue swelling from birth trauma and does not require intervention.

F.A respiratory rate of 44 breaths/min is within the normal range (30–60 breaths/min) for a newborn and does not indicate distress.

A. "Hypnosis can be beneficial if you practiced it during the prenatal period." B. "Synchronized breathing will be required during hypnosis." C. "Focusing on controlling body functions will be helpful during hypnosis." D. "Hypnosis does not work for controlling pain associated with labor."

Correct Answer is A

Explanation

A. "Hypnosis can be beneficial if you practiced it during the prenatal period":

This statement is accurate. Hypnosis techniques for pain management during labor can be more effective if the client has practiced and familiarized themselves with the techniques during the prenatal period. Regular practice can help the client achieve a deeper state of relaxation and better utilize hypnosis for pain control during labor.

B. "Synchronized breathing will be required during hypnosis":

While synchronized breathing techniques can be part of hypnosis practice, it is not necessarily a requirement for hypnosis to be effective for pain management during labor. Different hypnosis techniques may focus on various aspects such as visualization, deep relaxation, or suggestion to manage pain.

C. "Focusing on controlling body functions will be helpful during hypnosis":

While focusing on controlling body functions, such as breathing or muscle tension, can be part of hypnosis techniques, it is not the only focus. Hypnosis for pain management during labor often involves guiding the mind to a state of deep relaxation and altering perceptions of pain rather than directly controlling body functions.

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

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