A nurse is caring for a newborn 1 hr following birth.
Medical History 1000:
39- week gestation
Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min
Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.
Hemoglobin
Hematocrit
Heart rate
Serum glucose
White blood cells
Respiratory assessment
Correct Answer : A,B,C,D,F
A, B Monitoring the newborn's hemoglobin and hematocrit levels are important due to the risk of anemia.
C. Monitoring the newborn's heart rate post-birth is crucial for assessing cardiac function and detecting any abnormalities.
F. Positive pressure ventilation was administered to the newborn for 1 minute after birth, indicating a need for respiratory support. The nurse should closely assess the newborn's respiratory status.
D. There may be concerns about the newborn's blood glucose levels, especially if there were any periods of hypoxia or stress during labor and delivery.
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Related Questions
Correct Answer is C
Explanation
Allowing the baby to drain one breast at each feeding helps ensure effective milk removal, which can alleviate breast engorgement. Emptying the breast thoroughly promotes milk flow and prevents milk stasis, which contributes to engorgement.
A Cold compresses provide temporary relief from discomfort but does not address the underlying cause of engorgement.
B Drinking herbal tea, may have limited evidence supporting its efficacy in reducing engorgement. While hydration is important for breastfeeding, relying solely on herbal tea may not be as effective as other strategies.
D Feeding the baby every 2 hours, is important for maintaining milk supply and preventing engorgement. However, it's essential to ensure the breast is fully drained at each feeding, regardless of the time interval between feedings.
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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