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. Assess for edema:

Assessing for edema is important in monitoring the client's condition as edema can be a sign of worsening preeclampsia. However, it is not an action that requires immediate intervention in the first hour postpartum.

B. Administer an IV bolus of lactated Ringer's:

Administering an IV bolus of lactated Ringer's is not typically indicated for a client with preeclampsia without severe features unless there is evidence of dehydration or hypovolemia. Intravenous fluids may be administered judiciously based on the client's clinical status and fluid balance.

C. Restrict daily oral fluid intake:

Restricting daily oral fluid intake is not recommended for a client in the immediate postpartum period, especially without severe features of preeclampsia. Adequate hydration is important for postpartum recovery and breastfeeding.

D. Obtain a prescription for misoprostol:

Misoprostol is a medication used for various purposes in obstetrics, including the prevention and treatment of postpartum hemorrhage. However, it is not specifically indicated for the management of preeclampsia without severe features. The priority in this situation is close monitoring and supportive care rather than medication administration.

A. Airborne B. Droplet C. Protective environment D. Contact

Correct Answer is D

Explanation

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

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