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 C
Explanation
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
Correct Answer is B
Explanation
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.