A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.
Correct Answer is D
Explanation
Choice A rationale:
Uterine hypertonicity is associated with labor complications, not placenta previa.
Choice B rationale:
A persistent headache is not a typical symptom of placenta previa.
Choice C rationale:
A firm, rigid abdomen is a sign of a possible uterine rupture, not placenta previa.
Choice D rationale:
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is correct.
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