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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This response does not respect the client's autonomy and right to confidentiality.
B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.
Correct Answer is B
Explanation
Rubella immunization is typically recommended for women who do not have immunity to rubella, especially before they become pregnant or during their next attempt to get pregnant. Rubella infection during pregnancy can lead to serious complications for the developing fetus, including congenital rubella syndrome, which can cause birth defects such as deafness, blindness, and heart abnormalities. Therefore, it is essential for women to be immunized against rubella to prevent these complications before becoming pregnant. It is not recommended to administer live vaccines such as the rubella vaccine during pregnancy due to the potential risk to the fetus.
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