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 D
Explanation
A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.
B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+-4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.
Correct Answer is D
Explanation
The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.
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