A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?

Place a pacifier in the baby's mouth.

Check the baby's diaper.

Have the mother feed the baby.

Assess the respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.

Choice B rationale

Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.

Choice C rationale

Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.

Choice D rationale

Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.

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Correct Answer is A

Explanation

Choice A rationale

A 37-year-old patient with obesity and pregnancy-induced hypertension presents multiple risk factors. Advanced maternal age, obesity, and hypertension collectively increase the likelihood of complications such as preeclampsia, gestational diabetes, and cesarean delivery, necessitating close monitoring and management.

Choice B rationale

A patient with preexisting hypertension and twins is indeed high-risk due to the combined strain on the cardiovascular system and potential for preterm labor or other complications associated with multiple gestations. However, the presence of pregnancy-induced hypertension and obesity in the first patient poses a slightly higher cumulative risk.

Choice C rationale

A 16-year-old patient with newly diagnosed gestational diabetes is at increased risk, particularly because of age and the potential for poorly managed diabetes leading to complications. However, this scenario presents fewer immediate cumulative risks compared to older age and existing hypertension.

Choice D rationale

A 28-year-old patient who had a premature birth three years prior must be monitored for signs of recurrent preterm labor. Yet, this history alone does not present as high a cumulative risk as older maternal age, obesity, and pregnancy-induced hypertension. .

A. Client will be infection free at discharge. B. Client will exhibit normal breathing function at discharge. C. Client will exhibit normal gastrointestinal function at discharge. D. Client will void without pain at discharge.

Correct Answer is B

Explanation

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

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A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?