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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

Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe preeclampsia to avoid exacerbating the condition.

Choice B rationale

Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.

Choice C rationale

A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a normal physiological response.

Choice D rationale

Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor progression closely.

A. Impaired intellectual development. B. Development of metabolic syndrome. C. Shoulder injury related to birth size. D. Changes in genetic expression. E. Increased risk for chronic illnesses.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Impaired intellectual development in children born to mothers with diabetes can occur due to fluctuating blood glucose levels, which can affect brain development.

Choice B rationale

Development of metabolic syndrome is more likely in children born to mothers with diabetes due to genetic predispositions and prenatal exposure to hyperglycemia.

Choice C rationale

Shoulder injury related to birth size, although a possible immediate complication, is not typically considered a long-term effect of maternal diabetes.

Choice D rationale

Changes in genetic expression can occur due to epigenetic modifications from exposure to maternal diabetes, potentially leading to various health issues later in life.

Choice E rationale

Increased risk for chronic illnesses, such as type 2 diabetes and cardiovascular diseases, is higher in children born to mothers with diabetes, due to genetic and environmental factors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pre-eclampsia with severe features at 38 weeks' gestation is being induced with IV oxytocin.Which of the following would warrant the nurse to stop the infusion?

Correct Answer is A

Explanation

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.

Correct Answer is ["A","B","D","E"]

Explanation

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?

The nurse is caring for the postpartum client.Which assessment finding should prompt the nurse to conclude that the administration of carboprost tromethamine (Hemabate) has been effective?

Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?

Included in the definition of tachysystole is:

The nurse in a prenatal clinic is assessing a patient who is at 37 weeks' gestation for twins.The patient reports increased discomfort and increased lower pelvic pressure.Which action does the nurse take with this patient?

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome.Which of the following statements by the newly licensed nurse indicate understanding of the teaching?

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?