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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

A.

Respiratory assessment

B.

Hemoglobin

C.

White blood cells

D.

Serum glucose

E.

Temperature

F.

Heart rate

G.

Hematocrit

Question Solution

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 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.

Correct Answer is C

Explanation

Choice A rationale

Irregular menses are not a direct risk factor for cervical cancer. While they can indicate hormonal imbalances, they are not strongly linked to cervical cancer risk.

Choice B rationale

Menopausal status and hormone replacement therapy (HRT) are more closely linked to breast cancer risks rather than cervical cancer. Cervical cancer is primarily associated with HPV infection.

Choice C rationale

Multiple sexual partners increase the risk of HPV infection, which is the primary cause of cervical cancer. HPV is a sexually transmitted infection that significantly raises the likelihood of developing cervical cancer.

Choice D rationale

A family history of breast cancer is more relevant to breast cancer risk rather than cervical cancer. Cervical cancer risk is more closely linked to HPV infection and sexual behavior.

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