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 D
Explanation
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.
Correct Answer is B
Explanation
Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that can be spread through contact with contaminated objects or people. Contact isolation precautions are used to prevent the spread of infectious organisms that are spread by direct or indirect contact. This includes wearing gloves and a gown when entering the client's room and removing them before leaving the room, as well as using dedicated equipment and ensuring proper disinfection of surfaces.
Droplet isolation precautions are used to prevent the spread of organisms that are spread by droplets from coughing, sneezing, or talking. Airborne isolation precautions are used to prevent the spread of organisms that can remain suspended in the air and travel long distances, such as tuberculosis. Protective environment precautions are used for clients who have compromised immune systems, such as those who have undergone a bone marrow transplant, and involve using special air filtration systems and limiting visitors to reduce the risk of infection.
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