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 A
Explanation
Potential Condition: Preterm labor. Based on the information provided, the patient is most likely experiencing preterm labor. Actions to Take: Administer tocolytics. If the patient is in preterm labor, the nurse should administer tocolytics to try to stop the contractions. Parameters to Monitor: Frequency of contractions. The nurse should monitor the frequency of contractions to assess the patient’s progress.
Correct Answer is A
Explanation
Choice A rationale
Painless vaginal bleeding at 28 weeks of gestation can be a sign of placenta previa or placental abruption, both of which are serious conditions that require immediate attention.
Choice B rationale
While vaginal spotting after a missed period could indicate early pregnancy, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
Choice C rationale
Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a medical emergency.
Choice D rationale
A cough and fever at 38 weeks of gestation could indicate an infection, which should be evaluated. However, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
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