A nurse in a newborn nursery is receiving change-of-shift report for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who is 24 hr old and has not had a meconium stool.
A newborn who has a short frenulum and is having difficulty breastfeeding.
A newborn who is 10 hr old and has onset tachypnea.
A newborn who is 30 hr old and has blood-tinged discharge in her diaper.
The Correct Answer is C
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Retained placental fragments is a risk factor for postpartum hemorrhage. After delivery, the uterus continues to contract to deliver the placenta.
Contractions also help to compress the blood vessels where the placenta was atached to the uterine wall.
Postpartum hemorrhage can happen if parts of the placenta stay atached to the
uterine wall.
Choice A is incorrect because pregnancy-induced hypertension is a risk factor for
postpartum hemorrhage.
Choice B is incorrect because meconium-stained fluid is not mentioned as a risk factor for postpartum hemorrhage in my sources.
Choice D is incorrect because oligohydramnios is not mentioned as a risk factor for postpartum hemorrhage in my sources.
Correct Answer is A
Explanation
A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn who is 6 hours old.
Feeding the newborn can help maintain their blood glucose level.
Choice B is not an answer because administering 50 mL of dextrose solution IV is not necessary for a newborn with a normal blood glucose level.
Choice C is not an answer because reassessing the blood glucose level prior to the next feeding is not necessary for a newborn with a normal blood glucose level.
Choice D is not an answer because obtaining a blood sample for a serum glucose
level is not necessary for a newborn with a normal blood glucose level.
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