ATI Maternal Newborn Medium 139 Questions

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

A community health nurse is contributing to the plan of care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first?

"Use spermicidal jelly whenever you use your diaphragm."

A nurse at a family-planning clinic is preparing to give a presentation to clients about using a diaphragm. Which of the following pieces of information should the nurse plan to include in the session?

Nutritional status

A nurse at a prenatal clinic is collecting data from an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following evaluations is the nurse's priority?

Inform the client that giving birth vaginally might not be possible

A nurse at a prenatal clinic is collecting data from an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minor were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take?

The client has Rh-positive blood.

A nurse in a provider's office is reviewing the medical record of a client who is at 28 weeks of gestation. The nurse should identify that prophylactic administration of Rh immune globulin is contraindicated for which of the following findings?

Frequent headaches

A nurse in an antepartum clinic is assisting with the care of a client who is at 24 weeks of gestation. Which of the following findings should the nurse report to the provider?

Glycosuria

A nurse in an antepartum clinic is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?

"You will probably first notice your baby moving when you are around 20 weeks of gestation."

A nurse in an outpatient setting is reinforcing education with a client who is pregnant. Which of the following statements should the nurse include in the teaching?

Administer immune globulin to the client to prevent fetal isoimmunization

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure?

Reduce ambient noise and lighting

A nurse is assisting with care for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development?

Abundant lanugo

A nurse is assisting with obtaining a New Ballard score for a newborn. Which of the following manifestations indicates prematurity?

Apply oxygen at 10 L/min via nonrebreather face mask

A nurse is assisting with the care of a client in active labor and notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?

Place the client in a lateral position

A nurse is assisting with the care of a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take?

Stop the oxytocin infusion

A nurse is assisting with the care of a client in labor who is receiving IV oxytocin. The nurse notes contractions lasting 3 minutes each. What action should the nurse take?

"The bleeding is minimal untill discontinue your IV medication."

A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make?

Prepare the client for an emergency cesarean delivery

A nurse is assisting with the care of a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take?

Assist the client into a side-lying position and continue to monitor

A nurse is assisting with the care of a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart-rate tracing. Which of the following actions should the nurse take?

Fetal heart rate decreased by 15/min

A nurse is assisting with the care of a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the charge nurse?

Fetal asphyxia

A nurse is assisting with the care of a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?

Assess the newborn for respiratory depression

A nurse is assisting with the care of a client who is in labor. She received meperidine for pain 1 hour prior to entering the second stage of labor. Which of the following actions should the nurse take?

Fetal heart rate baseline of 90 bpm

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Implement seizure precautions

A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform?

Irregular development of the hip socket

A nurse is assisting with the care of a newborn who has a positive Ortolani sign. Which of the following manifestations should the nurse expect?

Prepare the client for delivery

A nurse is assisting with the care of a pregnant client at 37 weeks of gestation who has a biophysical profile score of 4. Which of the following actions should the nurse anticipate taking?

Group B streptococcus B-hemolytic culture

A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain?

"This type of monitoring will allow us to measure the intensity of your contractions."

A nurse is assisting with the preparation of a laboring client who is scheduled to receive an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make?

A 12-hour-old newborn who has a heart rate of 70/min whilesleeping

A nurse is caring for 4 newborns. Which of the following findings should the nurse report to the provider?

Advise the parent to feed the newborn

A nurse is caring for a 12-hour-old newborn who is asymptomatic and has a blood glucose level of 32 mg/dL. Which of the following actions should the nurse take?

"Your baby wasn't susceptible to substances during the first 2 weeks of your pregnancy."

A nurse is caring for a client at her first prenatal visit. The client is worried about the health of her fetus because she drank alcohol and smoked in the first week of pregnancy, before she knew she was pregnant. Which of the following responses should the nurse make?

Pelvic hematoma

A nurse is caring for a client following a forceps-assisted birth. The nurse should identify which of the following findings as a complication of this procedure?

Ask the client to drink a glass of orange juice

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test?

"The shape of your pelvis is ideal for vaginal childbirth."

A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make?

"You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan?

Administer ferrous sulfate orally

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? (Click on "Figure/Media" above the question for additional information about the client)

Massage the fundus

A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first?

Instruct the client to apply cold compresses.

A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?

Use a 20-gauge needle and administer the medication using the Z-track method

A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?

Assist the client to the bathroom

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first?

Provide a sitz bath with warm water

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take?

Ask the client about the family's cultural beliefs

A nurse is caring for a client who is postpartum. After bringing the newborn back to the parent following an assessment, the parent immediately gives the infant to the grandparent. Which of the following actions should the nurse take?

Notify the unit charge nurse and the rapid response team

A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take?

A certified nurse midwife

A nurse is caring for a client who is pregnant and states she would like to find a midwife with the highest possible level of education. Which of the following should the nurse recommend?

Assist the client in breathing into a paper bag

A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take?

Fetal heart tones auscultated by Doppler

A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy?

Tremors

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider?

Frequent stimulation

A nurse is caring for a newborn who was born to a client with narcotic use disorder. Which of the following nursing actions is contraindicated for the care of the newborn?

A newborn who is large for gestational age

A nurse is caring for four newborns. Which of the following newborns is at the greatest risk for hypoglycemia?

A client who is breastfeeding a 7-month-old infant

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives?

Ask the client when she last voided

A nurse is collecting data from a client on the first postpartum day. Findings include a fundus that is firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take?

Presence of ketones in the urine

A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect?

Deep tendon reflexes 4+

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication?

Measure the height of the fundus in fingerbreadths in relation to the umbilicus

A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use?

Pelvic and uterine pain is present while at rest.

A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings should the nurse report to the provider?

Fetal scalp electrode

A nurse is collecting data from a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider?

Foul-smelling lochia

A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis?

Urine output 20 mL/hr

A nurse is collecting data from a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider?

Nausea in the morning

A nurse is collecting data from a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy?

Urine ketones

A nurse is collecting data from a client with suspected hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first?

There is decreased abdominal movement with breathing.

A nurse is collecting data from a male newborn. Which of the following findings should the nurse report to the provider?

Decreased temperature

A nurse is collecting data from a newborn who has hypoglycemia. Which of the following findings should the nurse expect?

Apical heart rate of 80/min while crying

A nurse is collecting data from a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?

Yellow tinge to the skin

A nurse is collecting data from a newborn who is 18 hours old. Which of the following findings should be reported to the provider?

Rapid respirations

A nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. Which of the following findings should the nurse report as an indication of meconium aspiration syndrome?

The newborn has urinated once since the circumcision.

A nurse is collecting data from a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider?

Central cyanosis

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider?

Grunting with expiration

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider?

Nails extending over the fingers

A nurse is collecting data from a newborn. Which of the following findings suggests the newborn is post-mature?

Lightening

A nurse is collecting data from a pregnant client who is at 38 weeks of gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following?

Expiratory grunting

A nurse is collecting data on the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress?

"You should plan to gain no more than 20 lb during your pregnancy."

A nurse is contributing to the plan of care for a client who is at 12 weeks of gestation and has a BMI of 45. Which of the following recommendations should the nurse make for the client regarding weight gain during her pregnancy?

Have the client place ice packs on her breasts 4 times per day

A nurse is contributing to the plan of care for a client who plans to formula-feed her newborn. Which of the following actions should the nurse include in the plan?

Change the newborn's position every 2 to 3 hours

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse recommend?

"I should replace my diaphragm every 2 years."

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching?

Persistent vomiting

A nurse is discussing the expected changes of pregnancy with a client who is at 8 weeks of gestation. Which of the following findings should the nurse tell the client to report to the provider during the first trimester?

"I should avoid waiting too long between feedings."

A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis?

Use a tape measure to obtain the greatest breadth and width of the head

A nurse is measuring the head circumference of a newborn. Which of the following actions should the nurse take?

Repeat the measurement after allowing the client to sit for 5 to 10minutes

A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmH. Which of the following actions should the nurse take?

"Try pelvic tilt exercises."

A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make?

Time of the client's last void

A nurse is preparing a client who is pregnant for an ultrasound. Which of the following pieces of information is the most important for the nurse to collect?

Apply the ointment in the lower conjunctival sac of each eye

A nurse is preparing to administer erythromycin ophthalmic ointment 0.5% to a newborn. Which of the following actions should the nurse plan to take?

Administer vitamin K in the newborn's thigh

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take?

Turn the newborn's head quickly to 1 side

A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take?

Axillary

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use?

Check the integrity of the cord clamp

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take?

Give examples of how eating well will help her to maintain a healthy weight during pregnancy

A nurse is providing care for a pregnant adolescent at 12 weeks of gestation who verbalizes a fear of gaining weight during her pregnancy. Which of the following actions should the nurse perform?

Continue to monitor the fetal heart tracings

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take?

"Losing 2.2 pounds each month would be acceptable."

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make?

"Do not become pregnant for at least 1 year."

A nurse is reinforcing discharge instructions with a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

Clean the newborn's face first using water

A nurse is reinforcing discharge teaching about bathing with the parent of a newborn. Which of the following instructions should the nurse include?

"I will apply petroleum jelly to my baby's penis for the first few days."

A nurse is reinforcing discharge teaching about circumcision care for the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

The newborn should appear satisfied after each feeding.

A nurse is reinforcing discharge teaching with a client about breastfeeding her newborn. Which of the following pieces of information should the nurse include?

"You should notify the provider immediately if either of your legs becomes swollen."

A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make?

Iron

A nurse is reinforcing nutritional teaching with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet?

"Place fresh cabbage leaves on your breasts."

A nurse is reinforcing postpartum teachings with a client who is non-lactating about breast discomfort. Which of the following interventions should the nurse discuss with the client?

"You should use warm water to wash your nipples."

A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make?

"I may notice increased cramping when I am feeding my baby."

A nurse is reinforcing teaching about breastfeeding with a client. Which of the following client statements indicates an understanding of the teaching?

1,000 mg

A nurse is reinforcing teaching about calcium intake with a client who is breastfeeding. Which of the following amounts of calcium is the daily recommended amount for a woman who is breastfeeding?

Avoid using diaper wipes on the site during diaper changes

A nurse is reinforcing teaching about circumcision care with a parent of a newborn. Which of the following instructions should the nurse include?

"I will warm the bottle of formula by placing it in a pan of hot water."

A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Mix 1 scoop of powdered formula with 2 oz of water

A nurse is reinforcing teaching about formula feeding with the guardian of a newborn. Which of the following pieces of information should the nurse include?

"I should wear a support bra for a few days."

A nurse is reinforcing teaching about lactation suppression with a client whose newborn will be bottle-fed. Which of the following client statements indicates understanding of the teaching?

Wash the newborn's face with plain warm water

A nurse is reinforcing teaching about newborn baths with a client who is 2 days postpartum. Which of the following pieces of information should the nurse include?

"If the test is reactive, that means your baby's heart rate ishealthy."

A nurse is reinforcing teaching about nonstress testing with a client who is pregnant. Which of the following pieces of information should the nurse include?

The client has given the newborn a name.

A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching?

"I should be careful to avoid becoming pregnant within the next month."

A nurse is reinforcing teaching about the rubella immunization with a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching

"You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis."

A nurse is reinforcing teaching about toxoplasmosis with a client who is pregnant. Which of the following instructions should the nurse include?

Progesterone

A nurse is reinforcing teaching with a client about hormonal changes during pregnancy. The nurse should identify that which of the following hormones plays a key role in preventing miscarriage?

"Do not eat swordfish, shark, or king mackerel while you are pregnant."

A nurse is reinforcing teaching with a client about nutrition during pregnancy. Which of the following instructions should the nurse include in the teaching?

Stress incontinence

A nurse is reinforcing teaching with a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include?

"I should have a small snack before bedtime."

A nurse is reinforcing teaching with a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching?

"You will have a cesarean birth prior to the onset of labor.!"

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching?

"Your risk for ectopic pregnancy increases with an IUD."

A nurse is reinforcing teaching with a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse reinforce with the client?

"You should apply witch hazel after voiding or defecating."

A nurse is reinforcing teaching with a client who has hemorrhoids following a vaginal birth. Which of the following statements should the nurse include in the teaching?

"Use your finger to release suction after feeding."

A nurse is reinforcing teaching with a client who is breastfeeding about strategies to prevent mastitis. Which of the following instructions should the nurse include?

"You have a higher risk for hypoglycemia due to breastfeeding."

A nurse is reinforcing teaching with a client who is breastfeeding and has pregestational diabetes controlled with insulin. Which of the following instructions should the nurse include?

"You should use fluoride-based toothpaste to prevent dental caries."

A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include?

Intracranial hemorrhage

A nurse is reinforcing teaching with a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn?

"I should apply the diaper loosely until the circumcision site is healed."

A nurse is reinforcing teaching with a parent about how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching?

"Pretend you are urinating and stop your urine streamintermittently."

A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make?

Place the shoulder harness in the slots that are level with thenewborn's shoulders

A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?

"I should discard any formula left in the bottle after a feeding."

A nurse is reinforcing teaching with the guardian of a newborn about formula preparation and feeding. Which of the following statements by the guardian indicates an understanding of the teaching?

Teach the parent to provide kangaroo care for the infant

A nurse is reinforcing teaching with the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to take?

Glucose 29 mg/dL

A nurse is reviewing laboratory findings for a newborn. Which of the following findings should the nurse report to the provider?

Advise the client to start iron and vitamin C supplementation

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take?

Reposition the client from side to side

A nurse is reviewing the fetal heart tracings for a client in labor and notes variable decelerations. Which of the following actions should the nurse take?

Hyperbilirubinemia

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate?

"Were your twins born vaginally or by cesarean?"

A nurse is reviewing the medical record of a client who is pregnant prior to her first prenatal visit and notes that her pregnancy history is documented as 4, 1, 0, 2, 2. When the client arrives for the visit, which of the following questions should the nurse ask?

"These feelings are common for expectant fathers in early pregnancy."

A nurse is speaking with an expectant father who reports feeling resentful of the attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse provide?

"I would like to hear more about why you do not want the sonogram, including any cultural reasons."

A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states, "I am here to have my regular prenatal checkup, but I do not want any pictures taken of my baby." Which of the following responses should the nurse make?

"If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder."

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide?

"Talk with your doctor about a prescription for acyclovir to treatyour symptoms."

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include?

"Clean the cord stump with tap water."

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include?

"Plan opportunities to get out of the house frequently."

A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include?

Providing local anesthesia to the perineum during delivery

A nurse on an antepartum unit is assisting the charge nurse with an in-service session for newly licensed nurses. Which of the following descriptions should the nurse identify as referring to a pudendal block?

Apply cold ice packs to the client's perineum

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take?

"The blood-tinged mucus is a result of pseudomenstruation."

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make?

"I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets."

The nurse is reinforcing discharge teaching with the guardians of a newborn about how to use a bulb syringe. Which of the following statements by a guardian indicates an understanding of the teaching?

"You must not become pregnant for 28 days after receiving this immunization."

The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include?

Serum glucose 120 mg/dL

The nurse is reviewing the laboratory results of a term newborn. For which of the following findings should the nurse notify the provider?