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A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.

Exhibits

Which of the following findings should the nurse report to the provider?

Select all that apply

A.

Coombs test result

B.

Glucose level

C.

Head assessment finding

D.

Intake and output

E.

Respiratory rate

F.

Heart rate

G.

Mucous membrane assessment

H.

Sclera color

Answer and Explanation

Correct Answer : A,D,G,H

In the context of the newborn's information, the nurse should report the following findings to the provider:

 A. Coombs test result:

Explanation: The Coombs test checks for the presence of antibodies that can destroy red blood cells. In the absence of information about any specific concern or risk factors, a Coombs test result may not be immediately necessary for a term newborn. The nurse should report this finding to the provider for clarification on why the test was performed.

D. Intake and output:

Explanation: The newborn has voided only once since birth. Infrequent voiding can be a concern, and the nurse should report this to the provider for further evaluation, as adequate urine output is important to assess renal function and hydration status.

G. Mucous membrane assessment:

Explanation: Mucous membrane color and moisture are important indicators of hydration. If there are abnormalities, such as pale or dry mucous membranes, the nurse should report this to the provider for further assessment.

H. Sclera color:

Explanation: The color of the sclera can indicate jaundice in a newborn. If the sclera color appears yellow or jaundiced, the nurse should report this finding to the provider for further evaluation.

The following findings are not typically of immediate concern in the given context:

 B. Glucose level:

 Explanation: While glucose levels are important in certain situations, there is no information suggesting a need for immediate concern about glucose levels in this case. The nurse can monitor blood glucose levels as part of routine care but does not need to report it without specific concerns.

C. Head assessment finding:

Explanation: The information does not provide details about any abnormal head assessment findings. If there are no specific concerns mentioned, the nurse may not need to report this finding unless there are abnormalities observed during routine assessments.

E. Respiratory rate:

Explanation: The respiratory rate is not highlighted as a concern in the given information. If there are no specific abnormalities or signs of respiratory distress, the nurse may not need to report this finding without additional information.

F. Heart rate:

 Explanation: The heart rate is not highlighted as a concern, and a normal Apgar score was noted at 5 minutes. If there are no specific concerns or abnormal findings related to the heart rate, the nurse may not need to report this finding without additional information.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

a. Muscle tone: flaccid Interpretation: This finding suggests a lack of muscle tone, which could be concerning. It may indicate a neurological issue or possible birth trauma. Interpretation: Indication that the client's condition is worsening. b. Respiration effort: good cry Interpretation: A good cry indicates that the newborn is able to breathe properly and is responsive. Interpretation: Indication that the client's condition is improving. c. Reflex irritability: cry Interpretation: The newborn's ability to cry in response to stimuli is a positive sign of reflex irritability and neurological function. Interpretation: Indication that the client's condition is improving. d. Color consistent with genetic background Interpretation: This suggests that the newborn's skin color is within the range typical for their genetic background. Interpretation: Unrelated to the diagnosis. e. Heart rate 140/min Interpretation: A heart rate of 140 beats per minute is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis. f. Axillary temperature 36.3°C (97.4°F) Interpretation: A temperature of 36.3°C (97.4°F) is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis.

Correct Answer is A

Explanation

A. The client urinates 30 ml/hr

Effective voiding after the removal of a urinary catheter involves the ability to produce an adequate amount of urine. A urine output of 30 ml per hour is within the normal range, indicating that the client is passing urine consistently, which is a positive sign of bladder function.

B. The uterine fundus is 2 cm above the umbilicus: The position of the uterine fundus is related to postpartum uterine involution and is not a direct indicator of effective voiding. It is more relevant to assessing the progress of the uterus returning to its pre-pregnancy state.

C. The bladder is distended upon palpation: A distended bladder is a sign of urinary retention, not effective voiding. If the bladder is distended, it indicates that the client may not be emptying the bladder properly.

D. The client does not feel the urge to urinate: Lack of urge to urinate could be a sign of urinary retention or impaired bladder function. A normal and healthy bladder function includes the sensation of the urge to void when the bladder is filling.

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