A newborn, who is 4 hours old, presents with the following symptoms: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonicity, and a weak cry.
What should the nurse do based on these findings?

Swaddle the infant in a warm blanket.

Document the findings in the record.

Place a pulse oximeter on the infant’s heel.

Obtain a heel stick blood glucose level.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

A. Measure the size of the scrotal sac for length and width. B. Observe the urethral opening on the surface of the penis when the newborn voids. C. Use a fingertip to palpate the inguinal canal for a weakening or indentation. D. Perform transillumination of the scrotal sac to visualize shadows of the testes.

Correct Answer is C

Explanation

Choice A rationale

Measuring the size of the scrotal sac does not verify the absence of testes.

Choice B rationale

Observing the urethral opening when the newborn voids does not verify the absence of testes.

Choice C rationale

If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.

Choice D rationale

Transillumination of the scrotal sac is not the first step in verifying the absence of testes.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Correct Answer is D

Explanation

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer is C

Explanation

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?