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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 B

Explanation

Choice A rationale

While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.

Choice B rationale

The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.

Choice C rationale

While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.

Choice D rationale

Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.

A. Swaddle the infant in a warm blanket. B. Document the findings in the record. C. Place a pulse oximeter on the infant’s heel. D. Obtain a heel stick blood glucose level.

Correct Answer is D

Explanation

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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?