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A nurse is assisting with the care of a newborn 1 hr after birth.

Select the 5 findings that the nurse should report to the provider.

Temperature

Respiratory findings

Serum glucose

Hematocrit

White blood cell count

Hemoglobin

Heart rate

Answer and Explanation

Correct Answer : B,F,G

Choice A:

Temperature. The newborn's temperature is within the normal range of 36.5°C to 37.5°C (97.7°F to 99.5°F) for axillary measurement. Therefore, this finding does not need to be reported to the provider.

Choice B:

Respiratory findings. The newborn's respiratory rate is above the normal range of 30 to 60 breaths per minute. The newborn also has a low oxygen saturation of 96%, which indicates possible respiratory distress. Therefore, this finding should be reported to the provider.

Choice C:

Serum glucose. The question does not provide any information about the newborn's serum glucose level, so this choice is irrelevant and does not need to be reported to the provider.

Choice D:

Hematocrit. The question does not provide any information about the newborn's hematocrit level, so this choice is irrelevant and does not need to be reported to the provider.

Choice E:

White blood cell count. The question does not provide any information about the newborn's white blood cell count, so this choice is irrelevant and does not need to be reported to the provider.

Choice F:

Hemoglobin. The question does not provide any information about the newborn's hemoglobin level, but it is known that newborns have higher hemoglobin levels than adults due to fetal hemoglobin. A high hemoglobin level can increase the risk of polycythemia, which can cause hyperviscosity, hypoxia, and hyperbilirubinemia. Therefore, this finding should be reported to the provider.

Choice G:

Heart rate. The newborn's heart rate is above the normal range of 110 to 160 beats per minute. A high heart rate can indicate tachycardia, which can be caused by various factors such as fever, dehydration, anemia, infection, or congenital heart defects. Therefore, this finding should be reported to the provider.

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Correct Answer is D

Explanation

Choice A reason:

Fetal heart rate irregularities are not a sign of hydatidiform mole, as this condition involves an abnormal fertilization of the egg that results in an abnormal or absent fetus.

Choice B reason:

A hydatidiform mole is more commonly associated with dark brown to bright red vaginal bleeding, not whitish discharge. The bleeding may resemble prune juice and is often a sign of the abnormality.

Choice C reason:

Rapidly dropping human chorionic gonadotropin (hCG) levels are not a sign of hydatidiform mole, as this condition causes very high levels of hCG due to the proliferation of trophoblastic tissue.

Choice D reason:

In a hydatidiform mole, the uterus often enlarges more rapidly than expected for the gestational age due to the overgrowth of trophoblastic tissue and the accumulation of fluid-filled vesicles. This excessive uterine enlargement is a key sign that could indicate the presence of a molar pregnancy.

A. Tremors B. Lethargy C. Hunger D. Jaundice E. Weak cry

Correct Answer is ["A","B","E"]

Explanation

Choice A:

Tremors. This is a sign of hypoglycemia in a newborn because low blood sugar can cause shakiness or jitteriness in the muscles. •

Choice B:

Lethargy. This is a sign of hypoglycemia in a newborn because low blood sugar can cause low energy, poor feeding, or lack of interest in eating.

Choice C:

Hunger. This is not a sign of hypoglycemia in a newborn because low blood sugar can actually reduce the appetite or cause feeding difficulties.

Choice D:

Jaundice. This is not a sign of hypoglycemia in a newborn because jaundice is caused by high levels of bilirubin in the blood, not low levels of glucose.

Choice E:

Weak cry. This is a sign of hypoglycemia in a newborn because low blood sugar can affect the vocal cords and the respiratory system, causing a weak or high-pitched cry.

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A nurse is assisting with the care of a newborn 1 hr after birth. Select the 5 findings that the nurse should report to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

Correct Answer is D

Explanation

What are signs of hypoglycemia in a newborn? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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A nurse is assisting with the care of a newborn 1 hr after birth.

Select the 5 findings that the nurse should report to the provider.