A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

A newborn who has blue hands and feet with an axillary temperature of 36.6°C (97.9°F)

A newborn who has lost 12% of her birth weight

A newborn who is 24 hr post-circumcision and has yellow exudate

A newborn who has a blood glucose level of 63 mg/dL

Answer and Explanation

The Correct Answer is A

A. The newborn with blue hands and feet (acrocyanosis) along with a normal axillary temperature of 36.6°C (97.9°F) could indicate a need for further assessment. While acrocyanosis can be normal in newborns, it is essential to monitor for any signs of respiratory distress or circulatory issues. Since this newborn is exhibiting a potential sign of compromised circulation, this infant should be attended to first.

B. A newborn who has lost 12% of her birth weight is concerning, as significant weight loss in newborns can indicate feeding problems or other underlying issues. However, this would not take precedence over potential acute issues like those indicated in option A.

C. A newborn who is 24 hours post-circumcision with yellow exudate is expected to have some discharge as part of the healing process. If the exudate is not foul-smelling and there are no signs of infection, this is typically a normal finding.

D. A newborn with a blood glucose level of 63 mg/dL is within the normal range for newborns, as acceptable levels are typically above 40 mg/dL. Therefore, this does not require immediate attention.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. applying petroleum jelly to the suppository, is not necessary and may interfere with the medication's absorption.
B. Inserting the suppository along the posterior vaginal wall as far up as one can go.
C. inserting the suppository 5 cm (2 in), is the incorrect technique for administering a vaginal suppository. It should be administered as high up as one comfortably can
D. assisting the client into a prone position, is unnecessary and not related to the administration of the suppository.

A. Provide the client with ice packs for her breasts. B. Advise the client to avoid using a breast pump. C. Have the client apply purified lanolin to her breasts. D. Encourage the client to wear a loose-fitting bra.

Correct Answer is A

Explanation

A. Ice packs can help reduce swelling and inflammation associated with engorgement by constricting blood vessels and reducing blood flow to the area, which can alleviate pain and discomfort.
B. Avoiding the use of a breast pump may exacerbate engorgement. It is appropriate to use a pump if needed for comfort or to facilitate breastfeeding.
C. While purified lanolin can help soothe sore nipples, it does not address the inflammation and swelling of engorgement.
D. A well-fitting, supportive bra is important, but it should not be too tight. It should provide adequate support without constricting the breasts.

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A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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