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A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.
Which assessment action should the nurse prioritize?

Conduct a gestational age assessment.

Weigh and measure the newborn.

Evaluate the neonatal reflexes’ reactivity.

Perform a drug screen for cocaine.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While conducting a gestational age assessment is important, it is not the priority in this situation.

Choice B rationale

Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.

Choice C rationale

Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.

Choice D rationale

Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.

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Correct Answer is D

Explanation

Choice A rationale

Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.

Choice B rationale

Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.

Choice C rationale

Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.

Choice D rationale

Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.

A. Clear the infant’s vision. B. Dilate the pupil so the red reflex can be visualized. C. Prevent herpes infection. D. Prevent eye infections.

Correct Answer is D

Explanation

Choice A rationale

The eye ointment used in newborns is not intended to clear the infant’s vision.

Choice B rationale

The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.

Choice C rationale

While the ointment does help prevent infections, it is not specifically targeted against herpes.

Choice D rationale

The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.

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A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

Correct Answer is D

Explanation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what is the purpose of the ointment.The nurse would be correct in stating that the purpose for using the ointment is to:

Correct Answer is D

Explanation

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A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.
Which assessment action should the nurse prioritize?