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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Correct Answer is C

Explanation

A. Expecting docusate sodium to produce a semi-fluid stool within 6 to 12 hours is incorrect. Docusate sodium is a stool softener that usually works within 1 to 3 days, not as quickly as 6 to 12 hours.
B. Decreasing the intake of high-fiber foods while taking docusate sodium is not advised. In fact, maintaining a high-fiber diet is essential for managing constipation effectively.
C. Taking docusate sodium with a full 8-ounce glass of water is correct. Adequate fluid intake is necessary to help the stool soften and facilitate bowel movements when using this medication.
D. Avoiding citrus fruits while taking docusate sodium is not necessary. Citrus fruits can be beneficial as part of a high-fiber diet to help alleviate constipation.

A. Choose a ⅝-inch needle to administer the vaccine. B. Administer the vaccine into the dorsal gluteal muscle. C. Use a 20-gauge needle to administer the vaccine. D. Administer 0.5 mL of the vaccine.

Correct Answer is D

Explanation

A: The recommended needle length for administering vaccines to newborns is usually ⅝ inch, but the needle choice can vary depending on the infant's size and age.
B: The preferred site for administering vaccines to infants is the vastus lateralis muscle in the anterolateral thigh, not the dorsal gluteal muscle.
C: The gauge of the needle can vary, and a 20-gauge needle may be appropriate depending on the specific vaccine and infant's size.
D: The standard dose for the hepatitis B vaccine for newborns is 0.5 mL.

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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

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has a new prescription for docusate sodium to treat constipation. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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