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
Explanation
Choice A rationale
Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing
fever promptly is a priority to stabilize both maternal and fetal conditions.
Choice B rationale
Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the
overall clinical picture should be prioritized.
Choice C rationale
Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics
and hydration.
Choice D rationale
Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential
complications.
Correct Answer is D
Explanation
Choice A rationale
A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.
Choice B rationale
Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.
Choice C rationale
Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.
Choice D rationale
Age less than 25 years is not a risk factor for breast cancer; risk increases with age.