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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old.

Exhibits

Which of the following findings should the nurse report to the provider? Select all that apply.

Glucose level.

Head assessment finding.

Coombs test result.

Sclera color.

Heart rate.

Intake and output.

Mucous membrane assessment.

Respiratory rate

Answer and Explanation

Correct Answer : D,F,G

Choice A rationale:
Glucose level is within the normal range (40 to 60 mg/dL), so it's not a complication.
Choice B rationale:
Caput succedaneum is a common finding in newborns who were delivered vaginally and is not a complication.
Choice C rationale:
A negative Coombs test is a normal finding and does not indicate a complication.
Choice D rationale:
Yellow sclera in a newborn can be a sign of jaundice, which should be reported to the provider.
Choice E rationale:
Heart rate is slightly elevated but within the normal range for a newborn (100-160/min), so it's not a complication.
Choice F rationale:
The newborn has not passed meconium stool since birth, which should be reported to the provider as it could indicate a complication.
Choice G rationale:
Dry mucous membranes can be a sign of dehydration, which should be reported to the provider.
Choice H rationale:
Respiratory rate is within the normal range for a newborn (30-60/min), so it's not a complication.

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Correct Answer is D

Explanation

Choice A rationale:
Evaluating urinary output is important postoperatively, but it does not address the immediate concern of vaginal bleeding.
Choice B rationale:
Replacing the surgical dressing is necessary if it’s saturated, but it does not address the immediate concern of vaginal bleeding.
Choice C rationale:
Applying an ice pack to the incision site can help reduce swelling and pain, but it does not address the immediate concern of vaginal bleeding.
Choice D rationale:
Administering a 500 mL lactated Ringer’s IV bolus can help increase uterine contractility and decrease bleeding. This is the most appropriate action for the nurse to take in this situation.

A. Remove the diaphragm 2 to 4 hr after intercourse. B. Insert the diaphragm up to 6 hr before intercourse. C. Wash the diaphragm with detergent soap between uses. D. Apply a vaginal lubricant to the diaphragm prior to insertion.

Correct Answer is B

Explanation

Choice A rationale:
Removing the diaphragm 2 to 4 hours after intercourse is incorrect because the diaphragm should be left in place for at least 6 hours after intercourse to prevent pregnancy.
Choice B rationale:
Inserting the diaphragm up to 6 hours before intercourse is correct. This allows time for the spermicide to become effective.
Choice C rationale:
Washing the diaphragm with detergent soap between uses is incorrect. Detergent soap can degrade the material of the diaphragm.
Choice D rationale:
Applying a vaginal lubricant to the diaphragm prior to insertion is incorrect. Lubricants can interfere with the effectiveness of the spermicide.

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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. Exhibits Which of the following findings should the nurse report to the provider? Select all that apply.

Nursing Test Bank

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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old.

Exhibits

Which of the following findings should the nurse report to the provider? Select all that apply.