A nurse on a maternal newborn unit is caring for a group of newborns. Which of the following information should the nurse report to the provider?
A newborn has an axillary temperature of 36.6° C (97.9" F)
A newborn has a 516 weight loss since birth 3 days ago.
A newborn has voided three times since birth 24 hr ago.
A newborn has a respiratory rate of 24/min.
The Correct Answer is B
Rationale:
A. An axillary temperature of 36.6° C (97.9° F) falls within the normal range for a newborn, which is 36.5–37.5° C (97.7–99.5° F). Mild variations within this range are expected due to environmental or handling factors. This does not require provider notification.
B. A 5 lb (≈2.3 kg) weight loss in 3 days is significantly above the expected 5–10% of birth weight loss in the first few days of life. Excessive weight loss in a newborn can indicate feeding difficulties, dehydration, insufficient milk intake, or underlying medical conditions. Rapid or substantial weight loss can lead to electrolyte imbalances, hypoglycemia, and other complications, making it imperative to report to the provider immediately for assessment and intervention, which may include supplemental feeding, monitoring hydration status, or evaluating for other medical issues.
C. Voiding three times in the first 24 hours is within the normal range for a newborn’s initial urine output. By 24 hours, it is common for a newborn to have 1–3 wet diapers, and frequency increases over the first few days. While monitoring voiding patterns is important, this does not indicate an urgent issue requiring provider notification.
D. A respiratory rate of 24/min is slightly below the normal newborn range of 30–60 breaths/min. Mild variations can occur during sleep or rest. While the nurse should continue to monitor the newborn for signs of respiratory distress (e.g., retractions, grunting, nasal flaring), this finding alone is less urgent than significant weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Meeting with a committee of nurses from each shift to discuss the conflict is an important step in resolving the issue, but it should not be the first action. Without a clear understanding of the underlying causes, the meeting may not effectively address the conflict.
B. Gathering information regarding the situation is the first step the nurse manager should take. This involves assessing the perspectives of all parties, identifying the source and severity of the conflict, and collecting objective facts. This step aligns with the nursing process and effective conflict management, as it ensures that any interventions are informed and appropriate.
C. Acknowledging the conflict and encouraging teamwork is a supportive approach, but it does not address the root causes. Without gathering information first, this action may be premature and ineffective in resolving the conflict.
D. Encouraging nurses to resolve the conflict autonomously may be suitable for minor disagreements, but in this case, a conflict between day and night shift staff likely affects unit function and patient care. The nurse manager must first assess the situation before deciding on the appropriate level of intervention.
Correct Answer is C
Explanation
Rationale:
A. Handling finances is addressed through a financial power of attorney, not an advance directive. Advance directives are focused on healthcare decisions, not financial matters.
B. A form for contacting a primary contact is not considered an advance directive. While it may be part of medical documentation, it does not specify healthcare decisions or treatment preferences.
C. Instructions regarding a durable power of attorney for healthcare are a key component of advance directives. This allows the client to designate a healthcare proxy or agent to make medical decisions on their behalf if they become unable to do so. Advance directives also often include living wills, which specify the client’s wishes regarding life-sustaining treatments.
D. Information about the disposition of the client’s body upon death is not part of an advance directive. This is typically addressed in a separate document, such as a funeral or burial plan.
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