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 ["A","C","D","E"]
Explanation
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to
monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord
compression effects. .
Correct Answer is A
Explanation
Step 1 is: 12 mg ÷ 6 mg/ml.
Step 2 is: 12 ÷ 6 = 2 ml. Answer: 2 ml