A nurse is caring for a newborn who is 4 hours old.

The newborn is lying in a bassinet, lightly swaddled.

The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis.
Respirations are rapid and unlabored.

What condition is the newborn most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the newborn’s progress?

Hypoglycemia

Neonatal Abstinence Syndrome

Cold Stress

Respiratory Distress Syndrome

Answer and Explanation

The Correct Answer is A

Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.

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Correct Answer is A

Explanation

Consuming foods served at cool temperatures can help alleviate nausea and vomiting during early pregnancy. Cold foods often have less aroma compared to hot foods, which can make them more tolerable for someone experiencing nausea.
Choice B rationale
Brushing teeth after each meal is a good oral hygiene practice, but it does not directly help with managing nausea and vomiting during early pregnancy.
Choice C rationale
Eating three large meals per day is not recommended for managing nausea and vomiting during early pregnancy. Instead, eating small, frequent meals throughout the day can help keep the stomach from becoming empty, which can exacerbate nausea.
Choice D rationale
Drinking plenty of water when feeling nauseated can help prevent dehydration, which can occur as a result of vomiting. However, it may not directly alleviate the feeling of nausea.

A. Protective environment B. Droplet C. Contact D. Airborne .

Correct Answer is C

Explanation

Choice A rationale
A protective environment is not typically required for clients with MRSA141516. This type of precaution is usually used for clients who are severely immunocompromised and need to be protected from any potential sources of infection.
Choice B rationale
Droplet precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis.
Choice C rationale
Contact precautions are recommended for clients with MRSA141516. This involves using personal protective equipment and limiting patient movement outside of the room.
Choice D rationale
Airborne precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through tiny airborne droplets, such as tuberculosis or chickenpox.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?

Correct Answer is A

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A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation precautions should the nurse initiate?

Correct Answer is C

Explanation

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