A nurse is caring for a newborn 8 hours of age
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
Axillary temperature 36.1°C (97°F)
Respiratory rate 78/min
Nasal flaring present
Blood-tinged mucus noted at the vaginal opening
Uric acid crystals observed in the urine
Breastfed x 1 in the past 6 hr for 10 min.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
-The client talks to her father and her best friend when she starts to feel sad. Effective: Seeking support from loved ones and communicating feelings is a positive coping mechanism for dealing with sadness.
-The client states she feels numb when thinking about the crash.
Ineffective: Feeling numb can indicate emotional detachment, which may suggest unresolved trauma and could be indicative of ineffective treatment.
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-The client states that she avoids driving altogether and takes the bus.
Effective: Avoiding triggering situations, such as driving, can be a healthy coping strategy to manage distress associated with traumatic events.
-The client reports sleeping 6 to 7 hours per night.
Effective: Sleeping adequately is essential for mental health and overall well-being. Reporting sufficient sleep suggests improvement.
-The client states she feels less jumpy and more relaxed.
Effective: Feeling less jumpy and more relaxed indicates a reduction in anxiety symptoms, suggesting that treatment has been effective in managing anxiety.
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