A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?
Platelets 200,000/mm3
Bilirubin 19 mg/dL
Blood glucose 45 mg/dL
Hemoglobin 22 g/dL
The Correct Answer is B
- A) A platelet count of 200,000/mm3 is within the normal range for a newborn and does not require immediate intervention.
- B) A bilirubin level of 19 mg/dL is high and suggests the possibility of hyperbilirubinemia, which can lead to jaundice and, in severe cases, kernicterus, a form of brain damage. This is a critical value that requires immediate attention.
- C) A blood glucose level of 45 mg/dL is on the lower end of the normal range, but it is not as immediately concerning as the elevated bilirubin level. Monitoring and appropriate feeding should address this issue.
- D) A hemoglobin level of 22 g/dL is high, indicating polycythemia, which can be a risk factor for hyperviscosity syndrome. However, it is not as urgent as the bilirubin level of 19 mg/dL. Monitoring and partial exchange transfusion may be considered if symptoms develop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.
Correct Answer is B
Explanation
A. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent
complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.
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