Question: Which of the following findings should the nurse report to the RN? Select all that apply.
Head assessment finding
Glucose level
Mucous membrane assessment
Intake and output
Respiratory rate
Heart rate
Correct Answer : E,F
Choice A rationale:
The head assessment finding is not mentioned as abnormal in the exhibits. The anterior fontanelle is soft and flat, which is a normal finding in newborns. This indicates that there is no increased intracranial pressure or dehydration. The head circumference and shape are also not noted to have any abnormalities, which suggests that the newborn’s head development is within normal limits.
Choice B rationale:
The glucose level is not provided in the exhibits. However, routine glucose monitoring is not typically required for healthy, term newborns unless they exhibit symptoms of hypoglycemia or have risk factors such as being large for gestational age, small for gestational age, or born to mothers with diabetes. Since the newborn is feeding well and has no signs of hypoglycemia, there is no immediate concern regarding glucose levels.
Choice C rationale:
The mucous membrane assessment shows that the mucous membranes are moist and pink, which is a normal finding. This indicates that the newborn is well-hydrated and has good perfusion. There are no signs of dehydration, pallor, or lesions in the oral cavity, which suggests that the newborn’s mucous membranes are healthy.
Choice D rationale:
The intake and output are adequate, as evidenced by the number of wet diapers and stools. The newborn has had six wet diapers and three stools in the past 24 hours, which is within the normal range for a healthy, breastfed newborn. This indicates that the newborn is receiving sufficient nutrition and is well-hydrated.
Choice E rationale:
The respiratory rate of 44/min is on the higher end of the normal range for newborns, which is typically 30-60 breaths per minute. However, it is important to monitor for any signs of respiratory distress or abnormalities, such as grunting, flaring, or retractions. Reporting this finding ensures that any potential issues are addressed promptly.
Choice F rationale:
The heart rate of 154/min is within the normal range for newborns, which is typically 120-160 beats per minute. However, it is on the higher end of the spectrum. Monitoring and reporting this finding is crucial to ensure that the newborn’s cardiovascular status remains stable and to rule out any underlying conditions that may require intervention.
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Correct Answer is A
Explanation
Choice A rationale
Checking the identity of individuals who come to remove the baby from the room is crucial for preventing infant abduction and ensuring the safety of the newborn.
Choice B rationale
Matching the bracelet on the baby with the footprint record each shift is not a standard practice for newborn identification and safety.
Choice C rationale
Scanning the baby’s identification bracelet each time they are checked on is not a common practice and may not be feasible.
Choice D rationale
Wearing an electronic bracelet when out of the room is a safety measure, but it does not replace the need for parents to verify the identity of individuals handling their baby.
Correct Answer is D
Explanation
Choice A rationale
Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.
Choice B rationale
Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.
Choice C rationale
Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.
Choice D rationale
Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .