Which assessment finding should the nursery nurse report to the pediatric healthcare provider?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Central cyanosis when crying. This finding indicates a potential issue with oxygenation, which is crucial for infant health. Central cyanosis suggests inadequate oxygenation of the central circulation and can be a sign of serious conditions such as respiratory distress or congenital heart defects. Option A, a blood glucose level of 45 mg/dl, though low, is not the most critical finding to report in this case as it is within the range of expected blood glucose levels in newborns. Option B, a blood pressure of 82/45 mmHg, is low but not as concerning as central cyanosis. Blood pressure values can vary widely in newborns, and this value alone may not be alarming. Option C, a non-bulging anterior fontanel, is actually a normal finding in a newborn and does not indicate an immediate concern. Educationally, it is important for nursery nurses to understand the significance of various assessment findings in newborns to provide safe and effective care. Recognizing and prioritizing abnormal findings, such as central cyanosis in this case, is crucial for timely intervention and ensuring the well-being of maternal and reproductive health clients.

Correct Answer: D

Rationale: (D) describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children.

Correct Answer: D

Rationale: The correct answer is D) Urine output 90 ml/4 hours, indicating magnesium sulfate toxicity in a client with severe preeclampsia. Magnesium sulfate toxicity can lead to decreased urine output due to renal failure, a serious complication. This is a critical sign for the nurse to recognize and intervene promptly to prevent further harm to the client. Option A) Deep tendon reflexes 2+ is a normal finding and not indicative of magnesium sulfate toxicity. Option B) Blood pressure 140/90 is within normal range for a pregnant client with preeclampsia and does not specifically indicate magnesium sulfate toxicity. Option C) Respiratory rate 18/minute is also a normal finding and not a specific indicator of magnesium sulfate toxicity. In an educational context, understanding the signs and symptoms of magnesium sulfate toxicity is crucial for nurses caring for maternal and reproductive health clients. Recognizing these signs promptly can help prevent serious complications and ensure the best outcomes for both the mother and the baby. Regular assessments and knowledge of potential complications are essential in providing safe and effective care to these clients.

Correct Answer: B

Rationale: The correct answer is B) Increase daily caloric intake is needed. During pregnancy, especially in the case of gestational diabetes, it is essential for the client to maintain stable blood sugar levels through a combination of proper nutrition and insulin management. Increasing daily caloric intake is important to support the nutritional needs of both the mother and the developing fetus. Option A) Insulin production is decreased during pregnancy is incorrect because in gestational diabetes, the body may become more resistant to insulin, leading to higher blood sugar levels that require proper management through external insulin administration. Option C) Injection requirements remain the same is incorrect because insulin requirements may change during pregnancy due to hormonal fluctuations and increased insulin resistance. The nurse should educate the client on potential adjustments needed based on blood sugar monitoring. Option D) Blood sugars need less monitoring in the first trimester is incorrect because blood sugar monitoring is crucial throughout the entire pregnancy, including the first trimester, to ensure optimal management of gestational diabetes and the well-being of both the mother and the baby. In an educational context, it is important for nurses to provide comprehensive and accurate information to clients with gestational diabetes to empower them to make informed decisions about their health and the health of their baby. Proper nutrition, insulin management, and monitoring are key components of managing gestational diabetes effectively.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is option A, which is to measure bilirubin levels using a transcutaneous bilirubinometer. This is the most appropriate initial step when observing a yellow tint to the skin in a newborn, as it helps in assessing for jaundice, a common condition in newborns due to the breakdown of red blood cells. Option B, reviewing maternal medical records for blood type and Rh factor, is not the immediate action required when assessing jaundice in a newborn. While maternal factors can contribute to neonatal jaundice, assessing bilirubin levels in the newborn is more crucial at this point. Option C, preparing the newborn for phototherapy, is premature without knowing the actual bilirubin levels. Phototherapy is a treatment for severe jaundice, but it should be based on bilirubin level results. Option D, evaluating cord results, is not the priority in this situation. While cord blood can provide some information, direct assessment of the newborn's bilirubin levels through a transcutaneous bilirubinometer is more immediate and accurate. Educationally, this question highlights the importance of prompt assessment and intervention in newborn care. Understanding the significance of jaundice in newborns and the appropriate steps to take is crucial for nurses working in maternal and newborn health settings. Early detection and management of jaundice can prevent complications and ensure optimal outcomes for the newborn.