A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?

Axillary temperature 36.5°C (97.7°F).

Nasal flaring.

Heart rate 158/min.

One void since birth.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B rationale:

This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.

Choice C rationale:

A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.

Choice D rationale:

Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.

Choice B rationale:

Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.

Choice C rationale:

Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.

Choice D rationale:

Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.

A. Peanut butter sandwich on wheat bread. B. A sliced apple and red grapes. C. A chocolate chip cookie with a glass of skim milk. D. A scrambled egg with cheddar cheese.

Correct Answer is B

Explanation

A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.

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A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?

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