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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

Choice B rationale

Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.

Choice C rationale

This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.

Choice D rationale

Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

A. Chadwick’s sign. B. Chvostek’s sign. C. Goodell’s sign. D. Cullen’s sign.

Correct Answer is D

Explanation

Choice A rationale

Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.

Choice B rationale

Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.

Choice C rationale

Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice D rationale

Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.

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A nurse is attending to a newborn 2 hours after birth. Which four observations should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

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A nurse is attending to a newborn 2 hours after birth.
Which four observations should the nurse report to the healthcare provider?