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
Explanation
The symptoms describe indicate the presence of DVT which is a serious complication associated with childbirth. In addition to advising the client to see her provider immediately, the nurse should suggest interventions such as limb elevate to promote venous return and minimize discomfort.
A. Massaging the affected area can dislodge the blood clot and lead to a pulmonary embolism.
C. Cold compresses may help reduce pain and inflammation, but they do not address the underlying issue of a potential DVT.
D. Flexing the knee while resting can help improve blood flow in the affected leg and prevent stagnation but does not address the issue.
Correct Answer is C
Explanation
A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client
urinate voluntarily. Administering an analgesic is not indicated based on the information provided.
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