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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Intermittent abdominal pain following passage of bloody mucus is not a sign of placenta previa, but rather of bloody show, which is a normal occurrence in late pregnancy as the cervix begins to dilate and efface.
Choice B reason:
Abdominal pain with minimal red vaginal bleeding is not a sign of placenta previa, but rather of abruptio placentae, which is a serious complication where the placenta detaches from the uterine wall before delivery.
Choice C reason:
A large amount of bright red vaginal bleeding without pain is a sign of placenta previa, which is a condition where the placenta covers part or all of the cervical opening. This can cause bleeding when the cervix dilates or contracts, especially in the third trimester. This is a medical emergency that requires immediate attention.
Choice D reason:
Severe abdominal pain with increasing fundal height is not a sign of placenta previa, but rather of uterine rupture, which is a rare but life-threatening complication where the uterus tears open along the scar line from a previous cesarean delivery or other uterine surgery. This can cause severe bleeding, fetal distress, and shock.
Correct Answer is ["A","B"]
Explanation
Choice A reason:
Slow growth is a common symptom of thalassemia, especially in children. It is caused by the reduced production of hemoglobin and red blood cells, which leads to anemia and poor oxygen delivery to the tissues. Slow growth can also affect the development of facial bones and cause deformities.
Choice B reason:
Fatigue is another common symptom of thalassemia, also related to anemia and low oxygen levels in the body. People with thalassemia may feel tired, weak, and short of breath even after mild physical activity. Fatigue can also affect their mood, concentration, and quality of life.
Choice C reason:
Hematoma is not a typical symptom of thalassemia. Hematoma is a collection of blood under the skin or in an organ, usually caused by trauma, injury, or bleeding disorders. People with thalassemia may have a higher risk of bleeding due to low platelet counts or frequent blood transfusions, but this does not necessarily result in hematoma.
Choice D reason:
Pruritus is not a typical symptom of thalassemia. Pruritus is a sensation of itching that can affect any part of the body. It can have many causes, such as dry skin, allergies, infections, or liver problems. People with thalassemia may experience pruritus as a side effect of iron overload or iron chelation therapy, but it is not a direct consequence of the condition.
Choice E reason:
Ecchymoses are not typical symptoms of thalassemia. Ecchymoses are large bruises that appear on the skin due to bleeding under the surface. They can be caused by trauma, injury, or bleeding disorders. People with thalassemia may have a higher risk of bleeding due to low platelet counts or frequent blood transfusions, but this does not necessarily result in ecchymoses.
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