A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Weight loss of 3%

Voided one time since birth

Central cyanosis

Apical pulse rate of 156/min

Answer and Explanation

The Correct Answer is C

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.

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Correct Answer is A

Explanation

A. Previous cervical cerclage:

Cervical cerclage is a surgical procedure performed to reinforce the cervix in women with a history of cervical insufficiency or cervical incompetence. Cervical insufficiency is a condition where the cervix begins to dilate prematurely, leading to an increased risk of preterm birth. By placing a cervical cerclage, the risk of preterm delivery due to cervical insufficiency is reduced. Therefore, a history of previous cervical cerclage indicates an increased risk for preterm delivery in subsequent pregnancies.

B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb):

A newborn weighing 2.5 kg (5.5 lb) at birth suggests that the infant was small for gestational age (SGA). While SGA infants may be at risk for various complications, such as intrauterine growth restriction (IUGR), it does not directly indicate an increased risk for preterm delivery in subsequent pregnancies. Therefore, this choice is not indicative of preterm delivery risk.

C. Previous reactive non-stress test:

A reactive non-stress test (NST) is a reassuring finding during pregnancy and indicates that the fetus is receiving adequate oxygenation and is not under distress. While the absence of a reactive NST might indicate fetal compromise and the need for further evaluation, a previous reactive NST does not necessarily indicate an increased risk for preterm delivery.

D. Previous delivery at 37 weeks gestation:

A delivery at 37 weeks gestation is considered full-term and does not indicate an increased risk for preterm delivery. In fact, delivering at 37 weeks is within the normal range of gestational age and is not typically associated with preterm birth risk factors. Therefore, this choice does not indicate an increased risk for preterm delivery.

A. Apply cortisone ointment on the lesions prior to birth. B. Administer erythromycin ointment in the newborn's eyes after birth. C. Anticipate a scheduled cesarean birth. D. Initiate IV penicillin G during the labor.

Correct Answer is C

Explanation

A. Apply cortisone ointment on the lesions prior to birth:

Cortisone ointment is not appropriate for the treatment of herpes simplex virus (HSV) lesions. Cortisone is a steroid medication that can suppress the immune response, potentially worsening the HSV infection. Additionally, cortisone ointment does not directly treat the virus or prevent its transmission. Therefore, applying cortisone ointment on the lesions would not be effective and could even be harmful to both the mother and the newborn.

B. Administer erythromycin ointment in the newborn's eyes after birth:

Erythromycin ointment is routinely used in newborns to prevent bacterial eye infections, such as those caused by Chlamydia trachomatis or Neisseria gonorrhoeae. However, it is not effective against viruses like HSV. Therefore, while erythromycin ointment is important for preventing bacterial infections in newborns, it does not address the risk of HSV transmission from the mother to the newborn during birth.

C. Anticipate a scheduled cesarean birth:

When a pregnant person has active genital herpes lesions near the time of delivery, a scheduled cesarean section (C-section) is often recommended to reduce the risk of neonatal herpes transmission. Delivering the baby via C-section can decrease the likelihood of the newborn coming into contact with the virus in the birth canal, thereby reducing the risk of neonatal herpes infection. This intervention is specifically targeted at preventing HSV transmission to the newborn and is considered the standard of care in such situations.

D. Initiate IV penicillin G during labor:

Penicillin G is an antibiotic used to treat bacterial infections, but it is not effective against viruses like HSV. Therefore, initiating IV penicillin G during labor would not prevent the transmission of HSV to the newborn. While antibiotics may be used in certain situations during labor to prevent bacterial infections, they do not address the risk of HSV transmission and are not indicated for this purpose.

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A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

Correct Answer is A

Explanation

A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

Correct Answer is C

Explanation

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