RN Nursing · Newborn Assessment · Practice question
A nurse is assisting with the care of a newborn 2 hr following birth. (Based on the provided Vital Signs, Nurses' Notes, Diagnostic Results, and Medical History) Select the 4 findings that the nurse should report to the provider.
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✓
Temperature
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✓
Respiratory findings
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✓
Serum glucose level.
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WBC count.
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✓
Hematocrit.
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Heart rate.
Answer & explanation
Correct: Temperature · Respiratory findings · Serum glucose level. · Hematocrit.
This question requires knowledge of normal newborn values at 2 hours of life. Without the case values explicitly restated in the options, the answer relies on which parameters are most clinically significant to report. Temperature is reportable if abnormal — newborns are at high risk for hypothermia (normal axillary temperature is 36.5–37.5°C); a low temperature may indicate cold stress or infection. Respiratory findings are reportable if abnormal — normal newborn respiratory rate is 30–60 breaths per minute; signs such as grunting, nasal flaring, or retractions suggest respiratory distress syndrome and require provider notification. Serum glucose is reportable if low — normal newborn glucose is greater than 45–50 mg/dL; hypoglycemia at 2 hours is common and dangerous, requiring prompt intervention. Hematocrit is reportable if abnormal — normal newborn hematocrit is 45–65%; polycythemia (above 65%) can cause hyperviscosity and organ damage, while anemia requires treatment. WBC count in a newborn at 2 hours is normally elevated (up to 30,000/mm³) due to physiologic stress of birth, so an elevated WBC alone is not reportable. Heart rate within the normal range of 110–160 beats per minute is also not concerning. Therefore, temperature, respiratory findings, serum glucose, and hematocrit are the four findings warranting provider notification.
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