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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

Coombs test result

Glucose level

Head assessment finding

Intake and output

Respiratory rate

Heart rate

Mucous membrane assessment

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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Correct Answer is B

Explanation

a: The diaphragm should be used with a spermicide, not a vaginal lubricant. Spermicide is necessary to kill sperm and increase the effectiveness of the diaphragm.

b: The diaphragm can be inserted up to 6 hours before intercourse, making it a convenient option for contraception. It should be left in place for at least 6 hours after intercourse but not more than 24 hours to ensure effectiveness.

c: The diaphragm should not be removed 2 to 4 hours after intercourse. It must remain in place for at least 6 hours after intercourse to provide effective contraception.

d:Washing the diaphragm with detergent soap can damage the latex and increase the risk of deterioration. It should be washed with mild soap and water or with a special cleanser recommended by the healthcare provider.

A. Fetal heart rate B. Fundal height C. Hgb D. Hct E. Platelet count F. Vaginal bleeding G. WBC count

Correct Answer is ["A","F"]

Explanation

In the context of a client at 32 weeks of gestation with complete placenta previa, the following assessment findings require immediate follow-up:

A. Fetal heart rate:

Explanation: An elevated fetal heart rate (174/min) may be indicative of fetal distress. This finding requires immediate follow-up to assess the well-being of the fetus.

F. Vaginal bleeding:

Explanation: A moderate amount of bright red vaginal bleeding is a concerning sign, especially in the context of complete placenta previa. It indicates active bleeding, and immediate follow-up is necessary to assess the severity of the situation and the well-being of both the mother and the fetus.

C & D. Hemoglobin (Hgb) and Hematocrit (Hct):

Explanation: Hemoglobin and hematocrit levels are important indicators of blood loss. Given the vaginal bleeding, these values need immediate follow-up to assess the extent of maternal blood loss and the potential need for blood transfusion.

The following assessment findings do not require immediate follow-up in the given context:

B. Fundal height:

Explanation: Fundal height (33cm) is typically measured to assess fetal growth. While it's important to monitor, it may not be an immediate concern unless there are other signs of fetal distress.

E. Platelet count:

Explanation: While platelet count is important, it may not require immediate follow-up unless there is evidence of severe bleeding and a potential risk of disseminated intravascular coagulation (DIC). In this scenario, attention to Hgb and Hct is more urgent.

G & H. White Blood Cell (WBC) count and Red Blood Cell (RBC) count:

Explanation: WBC count and RBC count may be monitored but do not require immediate follow-up unless there are signs of infection or other complications not evident in the given information.

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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

Nursing Test Bank

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A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa Exhibits Which of the following assessment findings requires immediate follow-up) Select all that apply

Correct Answer is ["A","F"]

Explanation

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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