A nurse is caring for a newborn 1 hr following birth.
The newborn was delivered via emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate. The Apgar score was 5 at 1 min.
Positive pressure ventilation was given for 1 min followed by free flow oxygen.
What finding should the nurse report to the provider?
Hemoglobin
Hematocrit
Serum glucose
Respiratory assessment
Temperature
The Correct Answer is D
Choice A rationale
Hemoglobin is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice B rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it is an important parameter to monitor in newborns, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice C rationale
Serum glucose is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice D rationale
A respiratory assessment is crucial for a newborn, especially one that has undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non- reassuring fetal heart rate. The newborn’s Apgar score was 5 at 1 min, which indicates significant distress, and positive pressure ventilation was given for 1 min followed by free flow oxygen. These factors make respiratory assessment a priority and one of the immediate findings that the nurse should report to the provider.
Choice E rationale
Temperature is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not typically associated with a hydatidiform mole. In fact, hCG levels are usually abnormally high with this condition.
Choice B rationale
Profuse, clear vaginal discharge is not a typical finding in a client with a hydatidiform mole. The client may experience vaginal bleeding, but it is often described as resembling ‘prune juice’ or 'grape clusters’56.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition involves the abnormal growth of placental tissue, often without the development of a viable fetus.
Choice D rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of the placental tissue.
Correct Answer is D
Explanation
Choice A rationale
Covering the cord with the diaper can create a moist environment that promotes bacterial growth and delays healing.
Choice B rationale
Washing the cord daily with mild soap and water is not recommended. It’s better to keep the cord dry and clean.
Choice C rationale
Applying petroleum jelly to the cord stump is not advised. It can create a moist environment that can delay the drying and falling off of the stump.
Choice D rationale
Giving a sponge bath until the cord stump falls off is the correct instruction. This prevents the stump from getting wet, which can delay healing and increase the risk of infection.
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