Nokea
A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?
- A. Heart rate 160/min
- B. Axillary temperature 36.8°C (98.2°F)
- C. Yellow-tinged skin
- D. Respiratory rate 42/min
Correct Answer: C
Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.
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A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?
- A. Caput succedaneum
- B. Jaundice
- C. Acrocyanosis
- D. Overlapping cranial sutures
Correct Answer: B
Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.
A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
- A. Contraction frequency of 2 minutes
- B. Contraction duration of 90 seconds
- C. Fetal heart rate of 150/min
- D. Urine output of 60 mL/hr
Correct Answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?
- A. Administer 1 oz of glucose water every 2 hours
- B. Feed the newborn 60 mL of formula every 4 hours
- C. Offer sterile water between feedings
- D. Initiate phototherapy
Correct Answer: D
Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.
A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Breastfeed the newborn every 2 hours
- B. Offer both breasts at each feeding
- C. Supplement feedings with formula at night
- D. Expect the newborn to sleep through the night at 1 month
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.
A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
- A. Hyperbilirubinemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypothermia
Correct Answer: B
Rationale: Newborns who are large for gestational age (LGA) are at risk for hypoglycemia due to increased insulin production. Hyperbilirubinemia (Choice A) is more commonly associated with ABO or Rh incompatibility. Hypercalcemia (Choice C) is not a common finding in LGA newborns. Hypothermia (Choice D) may occur in newborns who are small for gestational age (SGA) due to a lack of subcutaneous fat for insulation, but it is not typically associated with LGA newborns.