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A nurse is caring for a newborn 8 hours of age

exhibits

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1°C (97°F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosal Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted. Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min

A.

Axillary temperature 36.1°C (97°F)

B.

Respiratory rate 78/min

C.

Nasal flaring present

D.

Blood-tinged mucus noted at the vaginal opening

E.

Uric acid crystals observed in the urine

F.

Breastfed x 1 in the past 6 hr for 10 min.

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

The temperature is slightly lower than the normal range for a newborn (which is typically around 36.5-37.5°C or 97.7-99.5°F), indicating potential hypothermia. This requires follow-up to ensure appropriate warmth and to monitor for any signs of infection.

The neonates heart rate is within the normal range

The respiratory rate is slightly elevated. This may indicate respiratory distress or another respiratory issue that requires further evaluation.

Yellow discoloration noted of sclera and oral mucosa: This could be indicative of jaundice, a common condition in newborns.

Nasal flaring can be a sign of respiratory distress and requires further assessment to determine the cause and appropriate management.

Blood-tinged mucus noted at the vaginal opening could indicate trauma or another issue related to delivery and should be evaluated to ensure there are no complications.

Uric acid crystals may also indicate dehydration or other metabolic issues that require further evaluation.

Newborns should breastfeed more often failure to which may indicate a problem in the sucking or sepsis.


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Related Questions

Correct Answer is D

Explanation

A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.

B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+-4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.

Correct Answer is ["B","D","F"]

Explanation

Correct Choices for Indicating Understanding:

  • "I should make sure that my baby feeds 8 to 12 times per day."
  • "My baby's stools should turn to a yellow color within the next day or two."
  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

Rationale

  • "Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

    • This statement does not necessarily indicate an understanding of discharge teaching, as supplementation should only be done based on medical advice and not solely based on perceived weight loss.

  • "I should make sure that my baby feeds 8 to 12 times per day."

    • This statement indicates an understanding of discharge teaching, as frequent feeding is important for newborns to ensure adequate nutrition and hydration, and to promote milk production in breastfeeding mothers.

  • "I should cover my sore nipples with plastic-lined breast pads after every feeding."

    • This statement does not indicate proper understanding, as plastic-lined breast pads can retain moisture and increase the risk of infection. Instead, breathable pads or natural remedies are often recommended.

  • "My baby's stools should turn to a yellow color within the next day or two."

    • This statement indicates an understanding of normal neonatal stool changes, as breastfed babies' stools typically transition to a yellow color within a few days of birth.

  • "I can increase my milk supply by drinking more water."

    • While staying hydrated is important, this statement alone is insufficient for indicating a comprehensive understanding of increasing milk supply. Effective breastfeeding practices and frequent nursing are more directly impactful.

  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

    • This statement indicates an understanding of the common experience of breast engorgement when milk comes in, which is a normal part of the breastfeeding process.

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