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.
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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Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.
B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.
C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.
D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.
E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.
F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.
G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.
Correct Answer is C
Explanation
A. History of ovarian cysts is not an absolute contraindication to oral contraceptives.
B. Hypotension is not a contraindication for oral contraceptives.
C. Migraine with aura is a contraindication due to increased risk of stroke associated with combined oral contraceptives in these clients.
D. Dysmenorrhea is often improved by oral contraceptive use and is not a contraindication.
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