A nurse is attending to a newborn 2 hours after birth.
Which four observations should the nurse report to the healthcare provider?
Body temperature.
Respiratory assessment.
Serum glucose level.
White blood cell count.
The Correct Answer is C
Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This statement is correct. It is recommended that newborns be breastfed 8 to 12 times per day, which is about every 2 to 3 hours.
Choice B rationale
Supplementing with formula after breastfeeding is not typically recommended unless there is a medical reason. Supplementing can interfere with the supply and demand process that increases milk supply.
Choice C rationale
Using plastic-lined breast pads can trap moisture and exacerbate sore nipples. It is recommended to use 100% cotton breast pads and to change them frequently to keep the nipples dry.
Choice D rationale
While staying hydrated is important for overall health, there is no definitive evidence that drinking more water will increase milk supply. However, some mothers find that staying well- hydrated helps with their overall comfort and well-being during breastfeeding.
Correct Answer is A
Explanation
Choice A rationale
If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.
Choice B rationale
Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.
Choice C rationale
Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.
Choice D rationale
Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.
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