A nurse is caring for a newborn 1 hour following birth in the emergency unit. Medical History: The newborn was born at 39 weeks gestation via emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. Apgar scores were 5 at 1 minute and 8 at 5 minutes. Positive pressure ventilation was given for 1 minute, followed by free flow oxygen.
Nurses' Notes: At 1000, the newborn was placed on a radiant warmer. The color is consistent with the newborn's genetic background, but acrocyanosis is present. Mild grunting, nasal flaring, and intermittent retractions are noted. The newborn appears restless and is being closely monitored. Vital Signs:Temperature: 36.6°C (97.9°F) Axillary Heart rate: 180/min Respiratory rate: 80/min Oxygen saturation: 96% Diagnostic Results:Hemoglobin: 9 g/dL (normal range: 14 to 24 g/dL)Hematocrit: 35% (normal range: 44% to 64%)Platelet count: 210,000/mm³ (normal range: 150,000 to 300,000/mm³)White blood cells: 9,500/mm³ (normal range: 9,000 to 30,000/mm³)Serum glucose: 38 mg/dL (normal range: 40 to 45 mg/dL)Querry: Select the 5 findings the nurse should report to the provider.Respiratory assessmentHemoglobinWhite blood cellsSerum glucoseTemperatureHeart rateHematocrit
Respiratory assessment
Hemoglobin
White blood cells
Serum glucose
Temperature
Heart rate
Hematocrit
Correct Answer : A,B,C,D,G
Choice A: Respiratory assessment
The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.
Choice B: Hemoglobin
The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.
Choice C: Serum glucose
The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.
Choice D: Heart rate
The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.
Choice G: Hematocrit
The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2
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Correct Answer is C
Explanation
Choice A rationale
A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.
Choice B rationale
A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.
Choice C rationale
Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.
Choice D rationale
A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.
Correct Answer is A
Explanation
Choice A rationale
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.