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
A nurse should report absent deep-tendon reflexes to the provider when a client is receiving magnesium sulfate via continuous IV infusion.
This is because reduced tendon reflexes can be a side effect of magnesium sulfate use during pregnancy.
Choice A is not correct because a decrease in the frequency of contractions is an expected outcome of magnesium sulfate use as a tocolytic to stop preterm labor.
Choice B is not correct because a urinary output of 35 mL/hr is within the normal range.
Choice D is not correct because an elevated blood pressure is not a known side effect of magnesium sulfate use during pregnancy.
Correct Answer is A
Explanation
Baked chicken is a food that the nurse should recommend for a client who is at
32 weeks of gestation and has cholelithiasis to include in her diet.
Eating healthy fats, like those found in lean meats such as chicken, can help the gallbladder contract and empty on a regular basis.
Choice B is incorrect because French fries are not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.
Unhealthy fats, like those often found in fried foods, should be avoided.
Choice C is incorrect because whole milk is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.
Unhealthy fats, like those often found in whole milk, should be avoided.
Choice D is incorrect because a bacon cheeseburger is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.
Unhealthy fats, like those often found in bacon and cheeseburgers, should be avoided.
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