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 D
Explanation
The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.
Correct Answer is ["A","B","C","E","F"]
Explanation
A The client reports a mild headache initially but then experiences a more severe headache along with dizziness. These symptoms could preeclampsia or gestational hypertension.
B. The client's presentations increase suspicion for preeclampsia which can lead to liver injury with right upper quadrant tenderness.
C. It is important to assess the respiratory rate as part of the overall evaluation of the client's condition considering the potential involvement of conditions like preeclampsia, which can affect multiple body systems.
E. The client's symptoms, including headache, dizziness, and inability to remove rings due to swelling, raise concerns for preeclampsia or gestational hypertension.
F. Monitoring fetal well-being is essential in the assessment of maternal conditions such as preeclampsia. If there are any concerns about fetal well-being, they should be reported to the provider.
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