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 B
Explanation
The nurse should use the lower ribcage border to measure chest circumference.
Choice A rationale:
The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.
Choice B rationale:
When measuring the chest circumference of a newborn, the correct anatomical landmark to use is the nipple line. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards. It's important to position the measuring tape at the level of the nipples, encircling the chest at its largest point, which typically aligns with the nipple line.
Choice C rationale:
The lower ribcage border is also not suitable as it may vary significantly with respiratory movements and is not a stable landmark for consistent measurements.
Choice D rationale:
The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.
Correct Answer is D
Explanation
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
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