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
Avocados are a good source of healthy fats, vitamins, and minerals, but they are not particularly high in calcium. They are beneficial for overall health but not specifically for increasing calcium intake.
Choice B rationale
Peanut butter is a good source of protein and healthy fats, but it is not a significant source of calcium. It can be part of a balanced diet but will not substantially increase calcium levels.
Choice C rationale
Yogurt is an excellent source of calcium, which is essential for bone health, especially during pregnancy. It also provides probiotics, which can aid in digestion and overall health.
Choice D rationale
Long grain rice is a good source of carbohydrates and some vitamins, but it is not high in calcium. It can be part of a balanced diet but will not significantly contribute to calcium intake.
Correct Answer is ["D","G","H"]
Explanation
Choice A rationale
Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.
Choice C rationale
A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
Choice D rationale
A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.
Choice E rationale
Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
Choice F rationale
Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.
Choice G rationale
A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
Choice H rationale
Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly.