A nurse is attending to a newborn 2 hours after birth.
Which four observations should the nurse report to the healthcare provider?
Body temperature.
Respiratory assessment.
Serum glucose level.
White blood cell count.
The Correct Answer is C
Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.
Choice B rationale
Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.
Choice C rationale
Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.
Choice D rationale
Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.
Correct Answer is A
Explanation
Choice A rationale
Hypotension, or low blood pressure, is a common complication from an epidural block16. This occurs because the medication used in the epidural can block sympathetic nerve fibers, which can cause blood vessels to dilate and lead to a drop in blood pressure16.
Choice B rationale
Vomiting is not typically a direct complication of an epidural block16. Nausea and vomiting during labor can have many causes, including the physical process of labor, pain, and medications.
Choice C rationale
Tachycardia, or a fast heart rate, is not typically a complication of an epidural block16. In fact, some of the medications used in an epidural can actually cause a slower heart rate.
Choice D rationale
While severe respiratory depression can occur with an epidural, it is extremely rare16. More commonly, an epidural can cause a feeling of breathlessness or difficulty taking a deep breath, but it should not cause significant respiratory depression.
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