Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Newborn has had 4 transitional stools during the shift

Urine output remains unchanged with a dark yellow appearance

Lungs clear, no retractions noted

Edematous area on right scalp softening, ecchymosis present

Total serum bilirubin 14.2 mg/dL

Facial bruising present with yellow discoloration of the face

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Transitional stools indicate progression from meconium to normal infant stool, reflecting adequate feeding and gastrointestinal function. These stools are typically greenish-brown to yellow and appear within the first few days of life. Four stools in one shift suggest active peristalsis and effective bilirubin excretion via feces. This is a positive sign in managing hyperbilirubinemia, as bilirubin is eliminated through the gastrointestinal tract, supporting clinical improvement.

Choice B rationale: Dark yellow urine may suggest concentrated output, potentially indicating suboptimal hydration. While unchanged output may seem stable, the color implies reduced fluid intake or increased bilirubin excretion. In neonates, urine should be pale yellow if hydration is adequate. Persistent dark urine warrants follow-up to assess feeding adequacy and renal function. It is not a definitive sign of expected progression and may signal a need for increased fluid intake.

Choice C rationale: Clear lungs and absence of retractions indicate effective respiratory function and no signs of distress. Retractions are a compensatory mechanism for increased work of breathing, often seen in respiratory compromise. Their absence, along with clear auscultation, suggests normal pulmonary transition and oxygenation. This finding confirms that the newborn is adapting well postnatally, with stable respiratory status and no need for supplemental oxygen or intervention.

Choice D rationale: Softening of the edematous scalp area and presence of ecchymosis suggest resolution of birth trauma, likely a cephalohematoma from vacuum extraction. As blood reabsorbs, firmness decreases and bruising becomes more apparent. This progression is expected and indicates healing. Monitoring is still required for bilirubin levels due to hemolysis, but the physical changes reflect normal recovery from localized trauma without signs of infection or worsening.

Choice E rationale: A total serum bilirubin level of 14.2 mg/dL remains above the normal range (1 to 12 mg/dL) and indicates ongoing hyperbilirubinemia. Although it has decreased from the previous day’s 18.5 mg/dL, it still exceeds the threshold for concern. Continued phototherapy and monitoring are necessary. This value does not yet reflect full resolution, so it cannot be considered a sign of expected progression without further decline.

Choice F rationale: Facial bruising with yellow discoloration suggests ongoing breakdown of red blood cells and bilirubin deposition in the skin. While bruising may resolve over time, the yellowing indicates persistent jaundice. This is a sign of elevated bilirubin and not a marker of improvement. It requires continued phototherapy and monitoring. Therefore, it does not indicate expected progression and warrants follow-up.

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 B

Explanation

Choice A rationale

The Babinski reflex is a primitive neurological reflex tested by stroking the sole of the foot. A normal response in a newborn is fanning of the toes, which indicates an intact central nervous system. This reflex, though important for neurological assessment, does not provide immediate data for evaluating respiratory or muscle tone complications, which are assessed by other parameters.

Choice B rationale

Heart rate is a critical component of the Apgar score, along with muscle tone, reflex irritability, color, and respiration. A low or declining heart rate (normal range 120-160 beats/min in a newborn) is often an early and sensitive indicator of hypoxia, circulatory compromise, or significant physiological distress, making it essential for immediate complication assessment.

Choice C rationale

The Moro reflex (startle reflex) is a primitive reflex observed by a sudden change in position. Its presence indicates neurological integrity. While its absence could signal a neurological or musculoskeletal injury, it is not an immediate parameter used for rapid assessment of cardiorespiratory stability in a distressed newborn like heart rate or blood glucose.

Choice D rationale

Blood glucose (normal 40-60 mg/dL) is important for energy homeostasis, and hypoglycemia can lead to lethargy, hypotonia, and respiratory distress. However, it is not as rapid or direct a measure of immediate oxygenation and perfusion status as the heart rate and respiratory effort are for determining acute complications.

A. The newborn reminds the client of themself as a newborn. B. The client reports fatigue and desire to sleep. C. The client does not want to feed the newborn. D. The client discusses a desire to have more children.

Correct Answer is C

Explanation

Choice A rationale

Identifying that the newborn resembles oneself as a baby is a normal and positive aspect of maternal-infant attachment and bonding, representing the "taking-hold" phase of postpartum psychological adjustment, where the mother focuses on the infant and parental role. This demonstrates integration and is not considered a psychosocial concern warranting intervention, indicating healthy psychological adaptation.

Choice B rationale

Reporting fatigue and a desire to sleep is a physiological and expected finding in the immediate postpartum period, largely due to the physical exertion of labor, blood loss, and hormonal shifts. While rest is important, this is considered a normal physical adjustment and not a primary psychosocial concern indicative of maladaptation or mental health issues, unlike severe mood or attachment disturbances.

Choice C rationale

A lack of desire to feed the newborn can signify impaired maternal-infant bonding, emotional withdrawal, or a potential symptom of postpartum mood disorders, such as postpartum depression, which is a significant psychosocial concern. This finding deviates from the expected "taking-hold" phase where the mother is typically focused on caring for and interacting with the infant, necessitating further psychosocial assessment.

Choice D rationale

Discussing a desire to have more children is a normal expression of future family planning and generally indicates a positive, healthy adaptation to the current newborn and the role of motherhood. This thought process does not suggest any immediate psychosocial concern or distress and reflects forward-looking reproductive health considerations and positive family construction.

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

Exhibits Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should further evaluate the cry characteristics, muscle tone, and respiratory characteristics to determine if the newborn is experiencing a complication.

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings reported by the client should the nurse identify as a postpartum psychosocial concern?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about home safety precautions with the guardian of a newborn. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching about the correct use of infant car seats with the parent of a newborn. Which of the following statements by the parent indicate an understanding of the teaching?

A nurse is collecting data from a newborn who has an infection of Candida albicans. Which of the following findings should the nurse expect?

A nurse is preparing to administer acyclovir 400 mg tablet PO three times per day. Available is 800 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Exhibits A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting dropdownthe nurse should plan todropdown.

A nurse is administering a miconazole vaginal suppository to a client who has vaginal candidiasis. Which of the following actions should the nurse take?

A nurse is caring for a newborn in the labor and delivery unit. Exhibits A nurse on the labor and delivery unit is assisting in the care of a newborn at 1 hr old. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

A nurse is caring for a client in an antepartum clinic following a maternal serum alpha-fetoprotein screening. The nurse should recognize that an elevated alpha-fetoprotein level is suggestive of which of the following?

Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.