A nurse is collecting data from a newborn who was born 2 hr ago. Which of the following findings should the nurse report to the provider?
Overlapping suture lines
Acrocyanosis
Hypotonia
Blood glucose level 40 mg/dL
The Correct Answer is D
A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.
Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.
Correct Answer is A
Explanation
A) Correct - Reporting crackles is important because they can indicate fluid retention in the lungs, which can be a serious adverse effect of terbutaline.
B) Incorrect- Dizziness is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
C) Incorrect- Nausea is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
D) Incorrect- Tremors are a common side effect of terbutaline and might not warrant immediate reporting unless severe.
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