The nurse is performing an assessment of a 12-hour-old newborn. Which finding(s) would require further action?
a. Respirations 40, irregular, shallow
b. Blood glucose 45 mg/dL
c. Absence of bowel elimination since birth
d. No urinary output since birth
e. Episodic apnea lasting 25 seconds
f. Jaundice on face and chest
ANS: D, E, F
Voiding should occur within 8 hours of birth. Jaundice occurring within the first 24 hours of life is considered pathologic, rather than normal physiologic jaundice. Episodic apnea lasting less than 15 seconds is considered normal, but apnea lasting more than 20 seconds requires further assessment. The first stool is typically passed during the first 24 hours following birth. Respirations are expected to be between 30 and 60 per minute and may be irregular and shallow.
You might also like to view...
Sleep disturbance in critically ill patients is defined as insufficient duration or stages of sleep that results in
a. less sleep that promotes recovery. b. discomfort and interferes with quality of life. c. adaptation of the environment to promote sleep. d. more sleep that promotes recovery.
Which presentations suggest the possibility of a factitious disorder? Select all that apply
a. Doctor shops, that is, goes from one doctor to another seeking the desired response b. Has a history of multiple hospitalizations without findings of physical illness c. If the desired response is not received, accuses staff of incompetence d. Claims illness to obtain financial benefit or other external incentive e. Has had multiple workups or even multiple exploratory surgeries f. Presents symptom profiles that do not ring true and are easily detected
The nurse is providing education on menopause to a group of female clients. Which of the following statements made by one of the clients would indicate the need for further instruction by the nurse?
1. "My periods may be irregular and less frequent.". 2. "Night sweats and hot flashes are commonly experienced.". 3. "My mood changes are a normal part of menopause.". 4. "Vaginal dryness may occur during menopause.".
The clinic nurse is teaching a group of HIV/AIDS clients about their disease process. They are discussing nutrition-related problems and how to control them. Which of the following are recommended for people with diarrhea? Select all that apply
A) Limiting food intake B) Increasing fluid intake C) Avoiding lactose D) Increasing intake of foods rich in pectin E) Drink liquids that are either hot or cold