A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?
A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old.
A hematocrit of 60% in an infant who is 8-hr old.
Jaundice in an infant who is 4-hr old.
Acrocyanosis in an infant who is 2-hr old.
The Correct Answer is C
A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.
B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion
C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.
D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not report the client's Hemoglobin level first to the primary health care because it falls within the normal range of 14 to 24 g/dL for a newborn. Therefore, it is not an immediate concern.
Choice B rationale:
The nurse should first report the client's Chest x-ray results to the primary health care. The diffuse pattern of radiopaque areas bilaterally on the chest x-ray suggests possible respiratory distress or other respiratory issues in the newborn. This finding requires immediate attention and intervention to ensure proper respiratory function.
Choice C rationale:
The nurse should not report the client's Glucose level first to the primary health care as 40 mg/dL is within the normal range of 30 to 60 mg/dL for a newborn. Though it is on the lower side, it is not critically low, and there are more urgent concerns to address.
Correct Answer is B
Explanation
A. Maintaining ambient room temperature at 24° C (75° F) can help prevent heat loss by keeping the environment warm, but it does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, which is not directly controlled by ambient temperature.
B. Drying the newborn's skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This action is critical immediately after birth when the newborn is wet with amniotic fluid.
C. Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air moves across the skin and carries heat away.
D. Placing the newborn on a warm surface helps reduce conductive heat loss by preventing heat transfer from the baby to a cooler surface. However, this does not address evaporative heat loss, which is specifically related to moisture evaporation from the skin.
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