A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.
Which of the following findings should the nurse report to the provider?
Select all that apply
Coombs test result
Glucose level
Head assessment finding
Intake and output
Respiratory rate
Heart rate
Mucous membrane assessment
Sclera color
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is A
Explanation
A. "You can bathe and dress your baby if you'd like to": This statement acknowledges the client's autonomy and offers a sensitive and supportive approach. Allowing the client the option to participate in the care of the baby, such as bathing and dressing, respects the individual grieving process.
B. "I'm sure you will be able to have another baby when you’re ready": While the nurse may want to provide hope for the future, this statement might be perceived as minimizing the client's current grief and loss. It's essential to focus on the present and the client's emotions.
C. "You should name the baby so she can have an identity": Naming the baby is a personal choice, and the nurse should avoid directing the client on what they "should" do. Naming the baby can be a meaningful way for some parents to acknowledge the baby's existence and create memories.
D. "If you don’t hold the baby, it will make letting go much harder": Pressuring the client to hold the baby may not be appropriate, as individuals have different coping mechanisms. Some may find comfort in holding and spending time with the baby, while others may need more time before they are ready.
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