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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 C

Explanation

Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.

A. The client will demonstrate proper bathing of the infant. B. The client will verbalize appropriate car seat safety. C. The client will identify individual family member roles. D. The client will have adequate nutritional intake.

Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

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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.

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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.