Nurses' Notes 0800:

Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted.

0830:

Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn's genetic background. Acrocyanosis present.

Select the 4 findings the nurse should report to the provider.

r.

Temperature

Respiratory assessment

Serum glucose level

WBC count

Hematocrit

Heart rate

Answer and Explanation

Correct Answer : B,D,E,F

Grunting, nasal flaring, and sternal retractions are signs of respiratory distress in a newborn. These findings suggest that the newborn is having difficulty breathing and may require further evaluation and intervention by the provider.

Hematocrit levels may be indicative of polycythemia or other hematological abnormalities, which could impact the newborn's well-being and require further assessment and management. Changes in heart rate may indicate cardiac or circulatory issues in the newborn, which warrant further evaluation by the provider.

Respiratory distress in the neonatal period can also occur due to neonatal sepsis and hence, WBC count is important.

Temperature is important to assess in newborns, but it is not explicitly indicated as abnormal in the scenario provided. Newborn's serum glucose level is essential, it is not mentioned in the scenario and is not typically a priority in this context unless there are specific risk factors or symptoms of hypoglycemia.

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Correct Answer is D

Explanation

Rationale

The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular blockade. The nurse should stop the infusion immediately.

A Monitoring blood glucose is important, but not a priority.

B. Magnesium sulphate toxicity is not an indication for emergency delivery.

C. Placing the client in Trendelenburg position is not appropriate in this situation. trendelenburg position could worsen respiratory depression and compromise the client's airway.

A. A backward sloping appearance of the forehead. B. Dilated scalp veins C. Over-riding suture lines D. Hypertension

Correct Answer is B

Explanation

Hydrocephalus is a condition characterized by the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. Manifestations of hydrocephalus in a newborn may include dilated scalp veins, sunset eyes, head enlargement and sutural diastasis due to increased intracranial pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Correct Answer is B

Explanation

A nurse is admitting an 8-hour old, term newborn following a cesarean birth. The nurse observes that the newborn's skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)