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 B
Explanation
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.
Correct Answer is C
Explanation
Choice A rationale
A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms
of preeclampsia appear.
Choice B rationale
A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.
Choice C rationale
A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.
Choice D rationale
A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.