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
Choice A rationale:
Newborns do not show interest in eating while crying. Crying is usually an indication of distress or hunger and not a state where they are interested in eating.
Choice B rationale:
Newborns are most interested in eating when they are in an "alert”. state. During this state, the baby is awake, calm, and attentive, making it an ideal time for feeding.
Choice C rationale:
In the "drowsy”. state, newborns may be sleepy and less interested in eating. They might feed less effectively in this state.
Choice D rationale:
"Active alert”. is a state where the newborn is awake, attentive, and active. While they may be interested in their surroundings, they may also be easily distracted during feeding.
Correct Answer is A
Explanation
Choice A rationale:
The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.
Choice B rationale:
Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.
Choice C rationale:
Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.
Choice D rationale:
Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.
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