Question

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old
Rationale:A blood glucose of 40 mg/dL for a 1-hr-old infant is within the expected reference range.
B. Acrocyanosis in an infant who is 2-hr old
Rationale: Acrocyanosis is a normal characteristic of a newborn's circulatory system. Acrocyanosis disappears within 24 to 48 hr after birth.
C. Jaundice in an infant who is 4-hr old
Rationale: Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately.
D. A hematocrit of 60% in an infant who is 8-hr old
Rationale: Infant hematocrit is high during the first few days after birth due to increased red blood cells received from the mother and from the infant's own production of red blood cells after birth.

Answer 1

The nurse should notify the charge nurse about jaundice in an infant who is 4 hours old as it can be indicative of hemolytic pathology, requiring immediate medical intervention.

Step-by-step explanation:

Among the situations presented regarding the care of newborn clients, the nurse should notify the charge nurse about jaundice in an infant who is 4 hours old. This finding is concerning as jaundice present within the first 24 hours of life can be indicative of a hemolytic pathology and requires immediate attention.

Acrocyanosis is expected in a newborn and should resolve within the first 24 to 48 hours. A blood glucose fingerstick of 40 mg/dL in a 1-hour-old infant falls within the acceptable range for newborns. A hematocrit of 60% in an infant who is 8 hours old, although elevated, is also generally expected and reflects increased red blood cell production.

The urgent nature of early jaundice stems from the risk of conditions such as hemolytic disease of the newborn, which can lead to serious complications if not addressed promptly. Therefore, the nurse's prompt response to this finding is essential for the wellbeing of the infant.