A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

A newborn who has blue hands and feet with an axillary temperature of 36.6°C (97.9°F)

A newborn who has lost 12% of her birth weight

A newborn who is 24 hr post-circumcision and has yellow exudate

A newborn who has a blood glucose level of 63 mg/dL

Answer and Explanation

The Correct Answer is A

A. The newborn with blue hands and feet (acrocyanosis) along with a normal axillary temperature of 36.6°C (97.9°F) could indicate a need for further assessment. While acrocyanosis can be normal in newborns, it is essential to monitor for any signs of respiratory distress or circulatory issues. Since this newborn is exhibiting a potential sign of compromised circulation, this infant should be attended to first.

B. A newborn who has lost 12% of her birth weight is concerning, as significant weight loss in newborns can indicate feeding problems or other underlying issues. However, this would not take precedence over potential acute issues like those indicated in option A.

C. A newborn who is 24 hours post-circumcision with yellow exudate is expected to have some discharge as part of the healing process. If the exudate is not foul-smelling and there are no signs of infection, this is typically a normal finding.

D. A newborn with a blood glucose level of 63 mg/dL is within the normal range for newborns, as acceptable levels are typically above 40 mg/dL. Therefore, this does not require immediate attention.

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Correct Answer is D

Explanation

A. Uterine atony
Uterine atony refers to the lack of muscle tone in the uterus after delivery, leading to excessive bleeding. This is not typically associated with abruptio placentae, which involves the premature separation of the placenta from the uterine wall during pregnancy, typically presenting with different symptoms such as painful contractions and bleeding.

B. Polyhydramnios
Polyhydramnios refers to an excessive amount of amniotic fluid during pregnancy and is not a characteristic of abruptio placentae. Polyhydramnios can be associated with various conditions but is not directly linked to placental abruption.

C. Painless vaginal bleeding
Painless vaginal bleeding is more characteristic of placenta previa, a condition where the placenta is abnormally positioned over the cervix. Abruptio placentae, on the other hand, typically presents with painful vaginal bleeding due to the detachment of the placenta from the uterine wall.

D. Board-like abdomen
A board-like abdomen is a classic sign of abruptio placentae, indicating significant uterine muscle contraction and possible internal hemorrhage. The sudden separation of the placenta can cause blood to accumulate behind the placenta, leading to a rigid, "board-like" feeling of the abdomen, which is a hallmark symptom of this condition.

A. Check the newborn's skin for ecchymosis. B. Assist the mother to breastfeed the newborn after birth. C. Obtain a stool sample of meconium D. Check the newborn's blood glucose level. E. Assist with administering a blood transfusion to the newborn

Correct Answer is ["A","B","D"]

Explanation

A. Correct. Large for gestational age (LGA. infants may have a higher risk of birth injuries, including ecchymosis (bruising) due to their size.
B. Correct. Encouraging breastfeeding is important for all newborns, including those who are large for gestational age.
C. This action is not specifically related to caring for a newborn who is large for gestational age. Meconium may be collected for other reasons, but it is not a priority in this situation.
D. Correct. LGA infants are at increased risk for hypoglycemia due to maternal gestational diabetes. Monitoring blood glucose levels is important.
E. This action is not typically indicated for newborns who are large for gestational age. It is important to focus on monitoring and providing supportive care unless there arespecific medical indications for a blood transfusion.

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A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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