A nurse is assessing a full-term newborn who is 24 hr old. Which of the following findings should the nurse report to the provider?
The newborn's neck is short and surrounded by skin folds.
The newborn's glucose level is 50 mg/dL
The newborn's sclerae have a yellowish tint
The newborn has experienced a weight loss of 3% since birth
The Correct Answer is C
A. The newborn's neck is short and surrounded by skin folds: A short neck with skin folds can be a normal variant in some newborns, especially those with subcutaneous fat. While it may warrant observation for potential anomalies, it is not an immediate concern at 24 hours of age.
B. The newborn's glucose level is 50 mg/dL: A glucose level of 50 mg/dL is within the normal range for a full-term newborn. Routine monitoring is sufficient, and this finding does not require urgent reporting.
C. The newborn's sclerae have a yellowish tint: Jaundice appearing within the first 24 hours of life can indicate pathological jaundice, which may result from hemolysis, infection, or metabolic disorders. Early-onset jaundice requires prompt evaluation and intervention to prevent complications such as kernicterus.
D. The newborn has experienced a weight loss of 3% since birth: A weight loss of up to 5–7% in the first few days after birth is considered normal due to fluid shifts. A 3% loss is expected and does not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood pressure 94/68 mm Hg: While slightly on the lower end for a 7-year-old, mild hypotension may not yet be present in severe dehydration because children often maintain blood pressure until significant fluid loss occurs. Blood pressure alone is not the earliest or most sensitive indicator of severe dehydration.
B. Urinary output 30 mL/hr: Normal urinary output for a child is approximately 1 mL/kg/hr. A child with severe dehydration typically has markedly reduced urine output (oliguria), so 30 mL/hr is still be within a low-normal range depending on the child’s weight
C. Respiratory rate 24/mn: This respiratory rate is within normal limits for a 7-year-old (approximately 18–25 breaths/min). It does not reflect compensation for dehydration or hypovolemia and is not a reliable indicator of severe fluid loss.
D. Heart rate 152/min: Tachycardia is an early and sensitive sign of hypovolemia in children. A heart rate of 152/min is significantly elevated for a 7-year-old, indicating compensatory mechanisms to maintain perfusion in response to severe dehydration.
Correct Answer is B
Explanation
A. Beef liver: Beef liver is high in cholesterol and saturated fat, which can increase serum cholesterol levels. Consuming liver is not recommended for clients managing hypercholesterolemia because it can exacerbate lipid abnormalities.
B. Egg whites: Egg whites contain protein without cholesterol or saturated fat. They are a heart-healthy alternative to whole eggs and can be safely included in a diet aimed at lowering or managing cholesterol levels.
C. Steamed clams: While clams are low in fat, they do contain some dietary cholesterol. In clients needing to strictly manage cholesterol intake, they should be consumed in moderation rather than emphasized as a primary protein source.
D. Broiled lobster: Lobster contains moderate amounts of cholesterol and should be limited in a cholesterol-lowering diet. Although broiling reduces added fats, the natural cholesterol content makes it less ideal than egg whites for daily consumption.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.