A nurse in a newborn nursery is organizing a plan of care for four newborns after receiving a change-of-shift report. Which of the following assessments should the nurse perform first?

Check the blood glucose level of a newborn who is 4 hr old and jittery.

Conduct a universal newborn screening on a newborn who is 26 hr old.

Conduct a New Ballard Score for a newborn who is 12 hr old.

Check the temperature of a newborn who is 2 hr old prior to the first bath.

Answer and Explanation

The Correct Answer is A

A. A jittery newborn at 4 hours old may be experiencing hypoglycemia, which is a potentially serious condition requiring immediate assessment and intervention.
B. Universal newborn screening is important but can be delayed until the newborn is more stable.
C. The New Ballard Score is an assessment of gestational age and can be done after stabilization.
D. Checking temperature prior to the first bath is important but less urgent than evaluating possible hypoglycemia.

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Correct Answer is ["A","B","C"]

Explanation

A. High-pitched, excessive crying is a common sign of neonatal abstinence syndrome (NAS).
B. Tachypnea (rapid breathing) is a typical respiratory symptom of NAS.
C. Body tremors and jitteriness are classic signs of withdrawal in newborns.
D. Newborns with NAS typically exhibit hyperactivity, not extreme lethargy.
E. Reflexes are usually increased (hyperactive), not decreased, in NAS.

A. Insert an indwelling urinary catheter immediately following the procedure. B. Apply sequential compression devices prior to the procedure. C. Perform a surgical timeout while the client is in the preoperative holding area. D. Initiate oxytocin via continuous IV infusion prior to the procedure.

Correct Answer is B

Explanation

A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.

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A nurse in a newborn nursery is organizing a plan of care for four newborns after receiving a change-of-shift report. Which of the following assessments should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

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