A nurse is caring for a newborn.
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 mucosa. 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
Yellow discoloration noted of sclera and oral mucosa
Nasal flaring present
Has voided and stooled one time since birth
Lung sounds clear bilaterally
Breastfed x 1 in the past 6 hr for 10 min
The Correct Answer is ["A","B","C","D","E","G"]
Answer:
- Axillary temperature 36.1° C (97° F)
- Respiratory rate 78/min
- Yellow discoloration noted of sclera and oral mucosa
- Nasal flaring present
- Has voided and stooled one time since birth
- Breastfed x 1 in the past 6 hr for 10 min
Rationale:
- Axillary temperature 36.1° C (97° F): This is below the normal newborn range (36.5–37.5° C). Hypothermia can lead to complications like hypoglycemia and respiratory distress, requiring immediate attention.
- Respiratory rate 78/min: A normal newborn respiratory rate is 30–60/min. A rate above 60 suggests tachypnea, which can indicate respiratory distress or underlying pathology.
- Yellow discoloration noted of sclera and oral mucosa: Jaundice appearing before 24 hours or worsening after 36 hours may indicate pathologic jaundice, such as from hemolysis, trauma (e.g., caput succedaneum), or sepsis.
- Nasal flaring present: This is a sign of increased respiratory effort and may signal respiratory compromise requiring prompt evaluation.
- Has voided and stooled one time since birth: A healthy newborn should void and pass stool multiple times by 36 hours. This finding raises concerns for dehydration or feeding issues.
- Breastfed x 1 in the past 6 hr for 10 min: Inadequate feeding can contribute to poor intake, weight loss, dehydration, and worsening jaundice. Feeding frequency should be every 2–3 hours in the early days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Would you like a picture taken of your baby after birth?" While photographs can be a deeply meaningful keepsake for grieving parents, this is not the most immediate or sensitive first option to discuss. It should be offered later, after establishing emotional readiness and providing space for the parents to process the loss.
B. The nurse should not discuss any options at this time: plenty of time will be available after the baby is born. Delaying these conversations may deny the mother the chance to prepare emotionally and make informed decisions. Nurses must provide timely, compassionate guidance to help the family begin their grieving process in a supportive environment.
C. "When your baby is born, would you like to see and hold her?" This is the most appropriate and compassionate option. Offering the mother the chance to hold and say goodbye to her baby helps in the grieving process and fosters emotional closure. It recognizes the baby as a real person and the loss as significant, while allowing the parents control over their experience.
D. "What funeral home do you want notified after the baby is born?" Although necessary eventually, discussing funeral arrangements too soon may feel abrupt or insensitive. These logistics are best addressed after more emotionally supportive interactions have occurred and when the parents feel more prepared to make such decisions.
Correct Answer is B
Explanation
A. It prevents the formation of Rh antibodies in newborns who are Rh positive: Rh immunoglobulin is administered to the mother, not the newborn. It does not prevent antibody formation in the infant; instead, it prevents maternal sensitization that can harm future pregnancies.
B. It prevents the formation of Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin works by suppressing the maternal immune response to fetal Rh-positive red blood cells. This prevents the formation of maternal anti-D antibodies, which could attack fetal red cells in future pregnancies.
C. It destroys Rh antibodies in mothers who are Rh negative: Rh immunoglobulin does not destroy antibodies already formed. If maternal sensitization has occurred and anti-D antibodies are already present, RhIg is no longer effective or indicated.
D. It destroys Rh antibodies in newborns who are Rh positive: RhIg has no role in treating or affecting the newborn’s immune system. It acts only in the Rh-negative mother to prevent alloimmunization after potential fetal-maternal blood mixing.
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