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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The nurse should first report the client's respiratory status to the primary health care.

Choice A rationale:

Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.

Choice B rationale:

Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.

Choice C rationale:

Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.

A. "I should crush cabbage leaves and place them on my breast.". B. "I will wear a snug-fitting bra.". C. "I should stimulate my nipples by squeezing softly.". D. "I will apply ice packs to my breasts.".

Correct Answer is C

Explanation

Choice A rationale:

Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.

Choice B rationale:

Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.

Choice C rationale:

Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.

Choice D rationale:

Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

In a newborn infant, which of the following is the liver's job related to bilirubin?

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.).

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

A nurse is reinforcing teaching with a parent about using an iron-fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?