Nurses' Notes 0800:
Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted.
0830:
Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn's genetic background. Acrocyanosis present.
Select the 4 findings the nurse should report to the provider.
r.
Temperature
Respiratory assessment
Serum glucose level
WBC count
Hematocrit
Heart rate
Correct Answer : B,D,E,F
Grunting, nasal flaring, and sternal retractions are signs of respiratory distress in a newborn. These findings suggest that the newborn is having difficulty breathing and may require further evaluation and intervention by the provider.
Hematocrit levels may be indicative of polycythemia or other hematological abnormalities, which could impact the newborn's well-being and require further assessment and management. Changes in heart rate may indicate cardiac or circulatory issues in the newborn, which warrant further evaluation by the provider.
Respiratory distress in the neonatal period can also occur due to neonatal sepsis and hence, WBC count is important.
Temperature is important to assess in newborns, but it is not explicitly indicated as abnormal in the scenario provided. Newborn's serum glucose level is essential, it is not mentioned in the scenario and is not typically a priority in this context unless there are specific risk factors or symptoms of hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
B. This statement indicates the client understands the importance of monitoring the incision site for any signs of infection, such as discharge, and knows to seek medical attention if these signs occur.
D. This statement indicates the client understands that while some discomfort is normal after a cesarean birth, unrelieved or severe pain could be a sign of complications and should be addressed promptly.
A. Resting in a recliner may not provide adequate support or promote proper healing of the incision site.
C. While continuing prenatal vitamins may be beneficial for overall health, it is not directly related to the cesarean birth recovery process.
E. A fever during the first week at home is not a typical occurrence and may indicate an infection, which should be evaluated by a healthcare provider. Therefore, it is not accurate to expect a fever during this time.
Correct Answer is D
Explanation
Rationale
Station refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis, which serve as a reference point during labor.
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