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A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR 96.6°F (35.9°C), 158, 62, jittery, pink body with bluish hands and feet, crying.
Which of the following nursing actions is of highest importance?

Swaddle the baby to provide warmth.

Assess the glucose level of the baby.

Take the baby to the mother for feeding.

Administer the routine neonatal medications.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.

Choice B rationale

Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.

Choice C rationale

Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.

Choice D rationale

Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale

PTB is the leading cause of neonatal mortality and for antenatal hospitalization. This is accurate because preterm birth (PTB) is a significant cause of infant mortality and often requires extended hospital stays for the management of complications.

Choice B rationale

PTBs result in increased numbers of neonatal and infant deaths and long-term neurological impairment. This is accurate because preterm births are associated with higher rates of mortality and long-term health issues in infants.

Choice C rationale

PTL is defined as regular uterine contractions resulting in cervical changes before 37 weeks gestation. This is accurate because preterm labor (PTL) is indeed characterized by these symptoms occurring before full-term pregnancy.

Choice D rationale

Average costs for premature/low birthweight infants are more than 10 times as high than for other newborns. This is accurate because medical care for premature and low birthweight infants is significantly more expensive due to the need for specialized care and extended hospital stays.

A. Check each urine for presence of ketones. B. Pad the client's bed rails and headboard. C. Provide visual and auditory stimulation. D. Place the bed in the high Fowler's position.

Correct Answer is B

Explanation

Choice A rationale

Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.

Choice B rationale

Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.

Choice C rationale

Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.

Choice D rationale

Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse educator is preparing a presentation on preterm labor (PTL) and birth (PTB). Which information does the nurse recognize as being inaccurate?

Correct Answer is A

Explanation

The nurse observes a new staff member caring for an eclamptic client following a seizure.Which of the following actions by the staff member indicates an understanding of eclampsia?

Correct Answer is B

Explanation

The nurse is assisting the primary care provider (PCP) with a vacuum-assisted delivery because of a prolonged second stage of labor.The nurse will inform the PCP when which guideline of the procedure is met?

A patient with pregestational diabetes mellitus delivers a neonate who is diagnosed with macrosomia.The nurse is aware that the neonate is at risk for additional long-term conditions related to maternal diabetes mellitus.Which long-term effects may occur? Select all that apply.

The nurse in a prenatal clinic is reviewing the files of four patients scheduled for visits.Which patient does the nurse identify as having the highest-risk pregnancy?

A postpartum client has been diagnosed with postpartum psychosis.Which of the following is essential to be included in the family teaching for this client?

Included in the definition of tachysystole is:

A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness.The nurse knows these are signs and symptoms of which obstetrical emergency?

A baby is grunting in the neonatal nursery.Which of the following actions by the nurse is appropriate?