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Ati nur 213 maternal newborn exam
Total Questions : 44
Showing 10 questions, Sign in for moreThe nurse is caring for a preterm formula fed infant. What finding would be most important to report to the healthcare provider?
A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?
Heart rate strong and regular
Brachial and femoral pulses strong and equal bilaterally
Respiratory rate 100/min with grunting, nasal flaring, and substernal retractions
Skin color consistent with genetic background with acrocyanosis
Chest x-ray reveals diffuse pattern of radiopaque areas bilaterally
Hemoglobin 13 g/dL (14 to 24 g/dL)
Hematocrit 43% (44 to 64%)
WBC 30,000/mm3 (9.000 to 30.000/mm3)
Platelets 149,000/mm3 (150,000 to 300,000/mm3)
Glucose 40 mg/dL (30 to 60 mg/dL)
Temperature 36.3° C (97.3° F)
Heart rate 140/min
Blood pressure 75/40 mm Hg
Respiratory rate 100/min
Oxygen saturation 96%
Weight 1.9 kg (4 lb 2 ounces)
Length 43.2 cm (17 in)
Medical History
A nurse is caring for a newborn who was born at 38 weeks of gestation.
A nurse is initiating the newborn's plan of care. Complete he following sentence by using the list of options.
The nurse should first address the client's
Explanation
Respiratory Status: The newborn is exhibiting signs of respiratory distress, including a respiratory rate of 100/min, grunting, nasal flaring, and substernal retractions. These findings indicate compromised respiratory function, which requires immediate attention to prevent hypoxemia or respiratory failure. The diffuse radiopaque areas on the chest x-ray suggest a condition like transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS), common in low-birth-weight infants.
Temperature: After stabilizing the respiratory status, addressing the newborn’s temperature is important. The temperature of 36.3°C (97.3°F) indicates mild hypothermia, which can further compromise respiratory function and glucose metabolism if not corrected. Warming the infant with skin-to-skin contact or using a radiant warmer is necessary to maintain thermoregulation.
A 1-day old newborn was born to a mother who had positive vaginal cultures for Group Beta Strep. The mother was only in labor for 1 hour prior to birth. What findings would indicate possible neonatal sepsis?
Complete the following sentence by using the list of options
There are two main hormones that have a significant role in lactation.
Explanation
Prolactin: This hormone, released by the anterior pituitary gland, stimulates the alveolar cells in the mammary glands to produce breast milk. Prolactin levels increase significantly after birth in response to the infant's suckling.
Oxytocin: Released by the posterior pituitary gland, oxytocin triggers the contraction of the myoepithelial cells surrounding the alveoli, causing milk to be ejected from the ducts, a process known as the let-down reflex.
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?
A newborn is experiencing symptoms of cold stress. Which assessment data by the nurse will require further evaluation for stress protocol? (Select All that Apply.)
The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?
The nurse is providing care for a neonate during the 3rd stage of labor. Which action does the nurse take during this stage?
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
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