The nurse notes that a newborn's white blood cell count (WBC) is 15,000. The nurse is aware that:.

This indicates a severe infection.

This is a normal WBC for a newborn.

This is a lab error.

You must call the doctor.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A white blood cell count of 15,000 does not necessarily indicate a severe infection. In newborns, WBC counts are typically higher than in adults, and they gradually decrease over the first few days after birth. A value of 15,000 falls within the normal range for a newborn and is not indicative of a severe infection.

Choice B rationale:

A white blood cell count of 15,000 is considered a normal range for a newborn. Newborns have higher WBC counts as a natural response to the stress of birth and exposure to the outside environment. The immune system is still developing, and elevated WBC counts are normal during this period.

Choice C rationale:

Assuming there are no other indications of lab error, such as abnormal results in other tests, it would be premature to label the WBC count as a lab error. Additionally, healthcare professionals should always consider the overall clinical picture before assuming a lab error based on a single result.

Choice D rationale:

There is no immediate need to call the doctor based solely on the WBC count of 15,000. Medical decisions should be made in the context of the newborn's overall clinical condition, and a single lab result does not warrant an immediate call to the doctor.

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Correct Answer is C

Explanation

Choice A rationale:

Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.

Choice B rationale:

Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.

Choice C rationale:

The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.

Choice D rationale:

Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.

A. Cephalhematoma. B. Nevus flammeus. C. Caput succedaneum. D. Molding.

Correct Answer is A

Explanation

Choice A rationale:

Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.

Choice B rationale:

Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.

Choice C rationale:

Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.

Choice D rationale:

Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.

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The nurse notes that a newborn's white blood cell count (WBC) is 15,000. The nurse is aware that:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who had a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.).

A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn. Which of the following statements by the parent indicates a need for further teaching?

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?