A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

Positive Moro reflex

Erythema toxicum

Acrocyanosis

Elevated bilirubin level

Answer and Explanation

The Correct Answer is D

A.   a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B.   erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C.   acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D.   an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.

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Correct Answer is D

Explanation

A. Nausea is a common side effect of terbutaline, but it is not typically a cause for concern. It may be managed with measures like taking the medication with food.
B. Tremors are a known side effect of terbutaline. While they may be uncomfortable for the client, they are an expected side effect and not necessarily indicative of a problem requiring immediate intervention.
C. Dizziness can occur as a side effect of terbutaline. It is important to monitor the client for this, but it is not typically a severe side effect that requires immediate reporting to the provider.
D. Crackles (also known as rales) in the lungs suggest the possibility of fluid accumulation, which could be a sign of pulmonary edema. This is a serious concern and should be reported to the provider promptly, as it may require a change in treatment or further evaluation.

A. “This infection can cause your baby to experience hearing loss at birth." B. “If you test positive for GBS, the provider will need to perform a cesarean birth." C. "You will be tested again for GBS at about 36 weeks of gestation." D. "You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby."

Correct Answer is C

Explanation

A: This infection does not directly cause hearing loss at birth. Hearing loss in newborns can be associated with genetic factors, birth complications, and certain infections, but GBS is not known to be a direct cause of hearing impairment.

B: A positive GBS test result does not necessitate a cesarean birth. The standard management for GBS-positive mothers is the administration of intrapartum antibiotic prophylaxis, not cesarean delivery, unless there are other obstetric indications.

C: Testing for GBS is typically done between 36 and 37 weeks of gestation because this timing is close to delivery, when the test results are most predictive of the baby's risk of exposure during birth.

D: Antibiotics are not given during the last 2 weeks of pregnancy to prevent GBS transmission. Instead, they are administered during labor to ensure effective levels of the drug during delivery, which is the critical period for preventing transmission to the baby.

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A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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