A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
Obtain blood glucose by heel stick.
Initiate phototherapy.
Monitor the newborn's blood pressure.
Place the newborn in a radiant warmer.
The Correct Answer is A
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nalbuphine (Nubain):Nalbuphine is an opioid agonist-antagonist, which can be used to treat moderate to severe pain. However, it is not specifically used to reverse the effects of fentanyl. Administering Nalbuphine could potentially complicate the situation by introducing another opioid into the system.
B. Naloxone (Narcan):Naloxone is an opioid antagonist that rapidly reverses the effects of opioids like fentanyl. It is the standard treatment for opioid overdose and can quickly restore normal respiration in a person whose breathing has slowed or stopped due to opioid use. This makes it the most appropriate drug to have readily available in this scenario.
C. Butorphanol (Stadol):Butorphanol is another opioid agonist-antagonist used for pain relief. Similar to Nalbuphine, it is not used to reverse opioid effects and could complicate the patient's condition by adding another opioid to the system.
D. Promethazine (Phenergan):Promethazine is an antihistamine used to treat nausea, vomiting, and allergies. It does not have any properties that would counteract the effects of fentanyl. Therefore, it would not be useful in reversing opioid-induced respiratory depression.
Correct Answer is D
Explanation
A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.
B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.
C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.
D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.
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