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caring for a newborn at term gestation who is large for
gestational age LGA. Which of the following actions
should the nurse take? Select all that apply. Click the
exhibit button for additional client information.
Laboratory reference rangeGlucose: Infant: 40-90 mg/dL
(2.2-5.0 mmol/L) - ANSWER-Assess the newborn for birth-
related injuries.
Monitor capillary blood glucose levels frequently.
Encourage the mother to breastfeed the newborn every 2-
3 hours.
Notify the healthcare provider if the capillary blood glucose
level is <40 mg/dL (2.2 mmol/L).
The nurse is teaching a class of expectant parents about
infant safety. Which of the following statements by a
participant would require follow-up? - ANSWER-"I will tie
bumper pads to the sides of the crib to protect my baby's
head."
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The nurse is monitoring a neonate 1 hour after
spontaneous vaginal delivery. Which of the following are
expected findings? Select all that apply. Click the exhibit
button for additional client information.
Laboratory reference range Glucose (random) - newborn
<24 hours old 40-60 mg/dL (2.2-3.3 mmol/L) - ANSWER-
Respirations of 56 breaths per minute.
Capillary glucose of 60 mg/dL (3.3 mmol/L).
White papules on bridge of the nose.
A newborn diagnosed with trisomy 18 (Edwards
syndrome) is on ventilator support. The client's parents
have repeatedly asked when their child will be able to
breathe without the ventilator. Which action by the nurse is
appropriate? - ANSWER-Facilitate a meeting between the
health care providers, palliative care team, and parents to
discuss care plan.
The nurse is performing the initial assessment of a
newborn. Which of the following findings should the nurse
report to the health care provider? Select all that apply. -
ANSWER-decrease muscle tone
Sacral dimple with a 0.4 in (1 cm) skin tag
Single artery in the umbilical cord
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The nurse is assessing a newborn at 1 minute of life. The
nurse notes the newborns is completely blue, has a heart
rate of 110/min, and is emitting a weak cry. The newborn
has active movement of extremities and grimaces when
the nares are suctioned. Which of the following Apgar
scores should the nurse assign the client? - ANSWER-
Apgar score of 6
The nurse is caring for a newborn who has a cleft palate.
Which of the following actions should the nurse take to
promote oral intake until the cleft palate is surgically
repaired? Select all that apply. - ANSWER-Use specialty
bottles or nipples
Burp the newborn often when feeding
Feed the newborn in an upright position
Initiate feeding as soon as possible after birth
the nurse is assessing a newborn with an infection due to
Candida albicans. Which assessment data support this
diagnosis? - ANSWER-White, adherent patches on the
tongue and palate
The nurse is assessing a 2-week-old client with tetralogy
of Fallot. Which of the following findings would be a priority
to follow up? - ANSWER-Hematocrit of 67% (0.67)
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The nurse is assessing a full-term newborn of a mother
with poorly controlled diabetes mellitus during pregnancy.
Which of the following findings would the nurse most likely
expect? - ANSWER-Elevated hematocrit level
The nurse is caring for a newborn shortly after birth. Which
of the following findings would be a priority to follow up? -
ANSWER-small tuft of hair at base of spine
The nurse is talking with the parent of a 1-day-old
newborn who had a circumcision using the plastic ring
method. Which of the following statements by the parent
would require follow-up? - ANSWER-"I understand that
yellow exudate on the area is a sign of infection."
A nurse is teaching a postpartum client about cord care for
the newborn. Which statement by the client indicates a
need for further teaching? - ANSWER-"I should use a
cotton swab to gently apply alcohol to the cord."
The nurse is observing a staff member caring for a client
who has a vaginal birth 30 minutes ago. The client is
having difficulty with breastfeeding and is requesting
assistance. The nurse should intervene if the staff member