A nurse is caring for a newborn 1 hr following birth.
Medical History 1000:
39- week gestation
Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min
Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.
Hemoglobin
Hematocrit
Heart rate
Serum glucose
White blood cells
Respiratory assessment
Correct Answer : A,B,C,D,F
A, B Monitoring the newborn's hemoglobin and hematocrit levels are important due to the risk of anemia.
C. Monitoring the newborn's heart rate post-birth is crucial for assessing cardiac function and detecting any abnormalities.
F. Positive pressure ventilation was administered to the newborn for 1 minute after birth, indicating a need for respiratory support. The nurse should closely assess the newborn's respiratory status.
D. There may be concerns about the newborn's blood glucose levels, especially if there were any periods of hypoxia or stress during labor and delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This action is important as it helps to prevent hypothermia, which newborns are particularly susceptible to. However, while drying the infant is essential, it should not be the very first action taken immediately after birth.
Stimulating the infant to cry can help establish normal respiratory function and is important for transitioning to extrauterine life. However, it may not be the first action if the infant is not breathing or appears to need immediate airway clearance.
This is a critical first step, especially if the newborn is not breathing adequately. Clearing the airway (using suction if necessary) is vital to ensure that the infant can breathe properly and transition well after birth. If there are any signs of airway obstruction or if the infant is not crying, this action takes precedence.
While cutting the umbilical cord is a standard procedure, it is typically performed after ensuring the infant is stable. Current guidelines suggest delaying cord clamping for a short period unless there are complications that require immediate action.
Correct Answer is []
Explanation
1. Potential Condition:
- Hypoglycemia: The newborn is jittery and has decreased muscle tone, which are common signs of hypoglycemia (low blood sugar), especially in a newborn large for gestational age.
2. Actions to Take:
- Check the newborn's capillary blood glucose level: This is crucial to confirm if hypoglycemia is the issue and to determine the appropriate treatment.
- Place the newborn under a radiant warmer: This action helps stabilize the newborn’s body temperature, which is important as hypoglycemia can sometimes be associated with temperature instability.
3. Parameters to Monitor:
- Temperature: Monitoring the temperature is important to ensure the newborn maintains normal body temperature and to identify any possible hypothermia.
- Seizure activity: Jitteriness can sometimes progress to seizures if hypoglycemia is severe, so monitoring for seizure activity is critical.
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