Question

the nurse is looking over a newborns plan of care regarding expected outcomes. which outcome would not be appropriate according to a newborns nursing care?

• the newborn will experience no bleeding episodes lasting more than 5 minutes.
• the newborns blood glucose will remain above 50 mg/dl
• the newborn will be correctly identified prior to separation from the parents.
• the newborns body temperature will stabilize between 97.8°f and 99.5°f (36.6°c and 37.5°c).

Explanation:

Analyze the clinical question

The question asks to identify which expected outcome is not appropriate for a newborn's plan of care. This requires evaluating each option against standard neonatal nursing guidelines.

Evaluate the bleeding outcome

Using the Immediate Newborn Care knowledge point, newborns have a temporary deficiency in coagulation factors due to a sterile gut and lack of Vitamin K. While Vitamin K is administered to prevent bleeding, any active bleeding episode in a newborn is abnormal. An outcome stating "no bleeding episodes lasting more than 5 minutes" is inappropriate because any bleeding episode is a critical concern that requires immediate intervention, not just those exceeding 5 minutes.

Evaluate the glucose outcome

Standard neonatal care guidelines state that a newborn's blood glucose level should ideally remain above \(40\text{ mg/dL}\) to \(45\text{ mg/dL}\) in the first hours of life, and stabilize above \(50\text{ mg/dL}\) thereafter. Thus, maintaining blood glucose above \(50\text{ mg/dL}\) is a safe and appropriate expected outcome.

Evaluate the identification outcome

Using the Patient Identification knowledge point, ensuring the newborn is correctly identified using matching bands before any separation from the parents is a fundamental safety standard. This is a highly appropriate outcome.

Evaluate the temperature outcome

Using the Newborn Thermoregulation knowledge point, maintaining a neutral thermal environment is vital. A normal newborn temperature ranges from \(97.7^\circ\text{F}\) to \(99.5^\circ\text{F}\) (\(36.5^\circ\text{C}\) to \(37.5^\circ\text{C}\)). The outcome of stabilizing between \(97.8^\circ\text{F}\) and \(99.5^\circ\text{F}\) is appropriate.

Answer:

• (A) The newborn will experience no bleeding episodes lasting more than 5 minutes. (Correct answer)
• (B) The newborn's blood glucose will remain above 50 mg/dl
• (C) The newborn will be correctly identified prior to separation from the parents.
• (D) The newborn's body temperature will stabilize between 97.8°F and 99.5°F (36.6°C and 37.5°C).