Rh: Positive. Action to Take 1: Obtain a transcutaneous bilirubin level. Action to Take 2: Administer methadone. Actions to Take: Monitor platelet count. Place the newborn under a radiant warmer. Check the newborn's capillary blood glucose level. Potential Conditions: Hyperbilirubinemia. Cytomegalovirus infection. Hypoglycemia. Neonatal abstinence syndrome. Parameters to Monitor 1: Temperature. Parameter to Monitor 2: Color and of bowel movements. Seizure activity. Frequent yawning. Petechiae. Respiratory rate: 68/min auscultation. Temperature: 36.1°C (96.9°F) axillary. Action to Take 1: Obtain a transcutaneous bilirubin level. Action to Take 2: Administer methadone. Actions to Take: Monitor platelet count. Place the newborn under a radiant warmer. Check the newborn's capillary blood glucose level. Potential Conditions: Hyperbilirubinemia. Cytomegalovirus infection.

Hypoglycemia. Neonatal abstinence syndrome. Parameters to Monitor 1: Temperature. Parameter to Monitor 2: Color and of bowel movements. Seizure activity. Frequent yawning.

Petechiae. Exhibit 1. What are the newborn vital sign ranges? Select all that apply. (Select All that Apply).

Temperature 97.7-99.3 axillary.

Heart rate asleep 100 bpm, 120-160 bpm, crying: 180 bpm.

Blood pressure not routinely assessed.

Respiratory rate 30-60 breaths per minute.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.

Choice B rationale:

The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.

Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.

Choice D rationale:

The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.

Choice C rationale:

Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.

Choice E rationale:

The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.

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Correct Answer is C

Explanation

Choice A rationale:

Wearing a supportive bra can actually help to manage engorgement, so it's not recommended to avoid wearing one during the day.

Choice B rationale:

Cold compresses are typically applied after feeding to reduce swelling, not before. Applying them before might hinder the milk let-down reflex.

Choice C rationale:

Frequent feeding can help to alleviate engorgement by ensuring that the breasts are being emptied regularly.

Choice D rationale:

Stopping breastfeeding until finishing antibiotics is not advisable, as it can lead to decreased milk supply and potential issues with engorgement. Antibiotics prescribed by a healthcare provider are usually safe to take while breastfeeding, and interrupting breastfeeding can exacerbate the engorgement problem. This choice is not appropriate for managing breast engorgement and is therefore incorrect.

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old. B. A hematocrit of 60% in an infant who is 8-hr old. C. Jaundice in an infant who is 4-hr old. D. Acrocyanosis in an infant who is 2-hr old.

Correct Answer is C

Explanation

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.

B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion

C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.

D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.

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Naxlex Comprehensive Predictor Exams

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Correct Answer is C

Explanation

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

How do you prevent flat spots on the back of a baby's head?

A newborn is most interested in eating in which wake and sleep state?

In a newborn infant, which of the following is the liver's job related to bilirubin?

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

A mother who is holding her 2-hour-old newborn says, "I don't think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.”. Which is the nurse's best response?