A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
A newborn who has a short frenulum and is having difficulty breastfeeding
A newborn who is 24 hr old and has not had a meconium stool
A newborn who is 30 hr old and has blood-tinged discharge in her diaper
A newborn who is 10 hr old and has new onset tachypnea
The Correct Answer is D
The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.
A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.
A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should report a platelet count of 60,000/mm to the provider as this value is below the normal range and can indicate severe preeclampsia or HELLP syndrome, both of which are serious conditions that require immediate medical intervention. The other values are within normal range for pregnancy.
Correct Answer is A
Explanation
Hypovolemic shock is caused by a significant loss of blood or fluids, resulting in decreased tissue perfusion and oxygenation. Cool, clammy skin is a classic symptom of hypovolemic shock, indicating that the body is redirecting blood flow to vital organs. A respiratory rate of18/min is within normal limits. Bounding pulses are associated with conditions such as hyperthyroidism or aortic regurgitation. A urinary output of 30 mL/hr is low, but it is not necessarily indicative of hypovolemic shock on its own.
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