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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.

A.

Glucose level.

B.

Head assessment finding.

C.

Coombs test result.

D.

Sclera color.

E.

Heart rate.

F.

Intake and output.

G.

Mucous membrane assessment.

H.

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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Related Questions

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

  • Subtract 3 months from June 21, which gives you March 21.
  • Add 7 days to March 21, which gives you March 28.
  • Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

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