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 C
Explanation
A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.
Correct Answer is A
Explanation
A. Breast enlargement is a common and expected change during pregnancy due to hormonal influences.
B. Skin mottling is not a typical pregnancy change.
C. Nipples usually become more prominent or everted, not inverted, during pregnancy.
D. Hair tends to become thicker and fuller during pregnancy, not thinner.
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