A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation.
A newborn who is 38 weeks of gestation is admitted to the newborn nursery following an emergency cesarean birth with respiratory distress syndrome (RDS). Apgar scores of 5 at 1 min and 7 at 5 min. The newborn received surfactant via an endotracheal tube and is currently receiving 3 Umin of oxygen via nasal cannula. Blood gases reveal respiratory acidosis.
Which action should the nurse prioritize in this situation?
Report the client's weight by the client's provider.
Select diagnostic studies followed by the primary health care.
Check brachial pulses for the client's respiratory status.
The Correct Answer is C
Choice A rationale:
Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.
Choice B rationale:
Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.
Choice C rationale:
Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Back to sleep: While placing babies on their backs to sleep is essential for reducing the risk of sudden infant death syndrome (SIDS), it does not prevent flat spots. Instead, tummy time while the baby is awake helps balance the time spent on their back.
B. Take the baby for walks: Taking a baby for walks is beneficial for overall development and stimulation but does not directly prevent flat spots on the head.
C. Keep them awake most of the day: This is not a safe or recommended practice. Babies need sufficient sleep for proper growth and development.
D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.
Correct Answer is B
Explanation
Choice A rationale:
Iron will facilitate bone growth. This statement is not accurate in the context of feeding a newborn with iron-fortified formula. While iron is essential for overall growth and development, its primary role is not specifically related to bone growth. Instead, it plays a crucial role in the production of hemoglobin, which helps carry oxygen in the blood.
Choice B rationale:
Newborns do not metabolize iron adequately. This statement is the correct choice. Newborns have limited iron stores that are obtained from their mothers during pregnancy. As they grow, their iron requirements increase, but their ability to metabolize iron is not fully developed at
birth. Hence, iron-fortified formula is recommended to provide the necessary iron for the newborn's healthy development.
Choice C rationale:
The newborn's iron source will start to deplete. This statement is not accurate in the context of iron-fortified formula feeding. The newborn's initial iron source is the iron stores passed on by the mother during pregnancy. However, the iron-fortified formula is designed to supplement and fulfill the baby's iron needs, preventing depletion of iron stores.
Choice D rationale:
Iron will facilitate eyesight development. This statement is not entirely accurate. While iron is important for many bodily functions, including eye health, it is not specifically responsible for eyesight development in newborns. Visual development in newborns is influenced by various factors, but iron intake through formula feeding directly impacting eyesight is not a primary concern.
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