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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.
Choice B rationale:
Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.
Choice C rationale:
Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.
Choice D rationale:
Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.
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.
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