Try Naxlex NCLEX-RN (Free-Trial)

 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.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.

The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:

b. Uterine tenderness.

Here's why:

  • Hypertension (a):While preeclampsia can increase the risk of abruptio placenta,it's not always present,and hypertension wouldn't be the immediate expected finding during the abruption event itself.
  • Fetal tachycardia (c):This can occur in early stages of abruption to compensate for decreased oxygen supply,but as the abruption becomes more severe,fetal bradycardia is more likely due to oxygen deprivation.
  • Leukorrhea (d):This is a white vaginal discharge and has no connection to abruptio placenta.

Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:

  • Vaginal bleeding (bright red or dark)
  • Abdominal pain or cramping
  • Sudden, ongoing uterine tightening or irritability
  • Fetal distress (decreased fetal heart rate movements)

Therefore, option b is the most expected finding in this scenario.

Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.

Correct Answer is A

Explanation

Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register