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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Back to sleep: While placing babies on their backs to sleep is essential for reducing the risk of sudden infant death syndrome (SIDS), it does not prevent flat spots. Instead, tummy time while the baby is awake helps balance the time spent on their back.

B. Take the baby for walks: Taking a baby for walks is beneficial for overall development and stimulation but does not directly prevent flat spots on the head.

C. Keep them awake most of the day: This is not a safe or recommended practice. Babies need sufficient sleep for proper growth and development.

D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.

A. Document this as an expected finding. B. Call the neonatologist to assess the newborn. C. Ask another nurse to verify the heart rate. D. Prepare the newborn for transport to the NICU.

Correct Answer is A

Explanation

Choice A rationale:

An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.

Choice B rationale:

Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.

Choice C rationale:

Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.

Choice D rationale:

Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.

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A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How do you prevent flat spots on the back of a baby's head?

Correct Answer is D

Explanation

D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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