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 purpose of bathing the newborn before initiating skin-to-skin contact is to decrease the risk of transmission of the virus from the mother to the newborn. Instructing the client to stop taking the antiretroviral medications at 32 weeks of gestation is incorrect as these medications should be taken throughout pregnancy to decrease the risk of transmission to the fetus.
Using a fetalscalp electrode during labor and delivery is also not an appropriate action as it increases the risk of transmission of the virus to the newborn. Administering a pneumococcal immunization to the newborn within 4 hours following birth is not specific to HIV positive newborns and is not related to preventing transmission of the virus.
Correct Answer is D
Explanation
Cytomegalovirus (CMV) is a viral infection that can cause serious health problems for newborns if acquired in utero. Some newborns may appear asymptomatic at birth but later develop complications such as hearing loss, intellectual disability, and vision problems. The virus can be transmitted through bodily fluids such as saliva, urine, and breast milk, and can be especially dangerous for premature infants or those with weakened immune systems. While macrosomia (large body size) and urinary tract infections are possible complications in newborns, they are not typically associated with CMV. Cataracts may also occur in infants with congenital CMV, but hearing loss is a more common complication.
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