Nokea
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
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Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The correct answers to report to the provider are A, B, and D.
A: Uterine contractions - Significant contractions could indicate preterm labor.
B: Fetal heart rate - Abnormal fetal heart rate can indicate fetal distress.
D: Vaginal examination - Risk of infection or cervical changes need provider evaluation.
C: Gestational age - Routine information, not typically requiring immediate provider notification.
E: Maternal blood pressure - Important but not typically urgent unless severely abnormal.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C: The car seat should be positioned in the car at a 45-degree angle. This statement demonstrates understanding because newborns who were born at 38 weeks of gestation may have poor muscle tone and need their car seat reclined at a 45-degree angle to keep their airway open. This position helps prevent the baby's head from falling forward and potentially obstructing their breathing.
Choice A is incorrect because using a sleep sack in a car seat can interfere with the proper fit and function of the harness system. Choice B is incorrect because a car seat challenge test is typically done for preterm infants to assess their ability to sit safely in a car seat, not for full-term newborns. Choice D is incorrect because current guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age, not turning it forward-facing at 1 year old.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice A) are not typically associated with nuchal cords. Periauricular papillomas (choice C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice D) is a common newborn rash that is not specifically linked to nuchal cords.
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.