A nurse is assisting with the care of a newborn who was born at 39 weeks of gestation and is 36 hr old.
Assessment
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants
Which of the following findings should the nurse report to the RN7 Select all that apply.
Glucose level
Mucous membrane assessment
Respiratory rate
Sclera color
Intake and output
Coombs test result
Heart rate
Head assessment finding
Correct Answer : B,D,F,H
A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.
Correct Answer is C
Explanation
A) Incorrect- Hydrocortisone ointment is not typically recommended for treating mastitis, as it might not address the underlying infection.
B) Incorrect- Wearing a well-fitting, supportive nursing bra can actually help alleviate discomfort and is not typically contraindicated in cases of mastitis.
C) Correct - Applying warm compresses to the affected breast can help reduce pain and discomfort associated with mastitis. Warmth can improve blood flow and promote milk flow.
D) Incorrect- Encouraging the client to limit oral fluid intake to decrease milk production is not a recommended approach, as maintaining proper hydration is important, especially when dealing with infection.
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