A nurse receives a handoff report.
Which newborn should the nurse assess first?
Glucose reading 58 mg/dl.
Temperature 97.4°F (36.3°C).
Respiratory rate 48 breaths/minute.
Pulse 134 beats/minute.
The Correct Answer is B
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While it requires attention and intervention to prevent hypoglycemia, it is not as immediately life-threatening as a significantly low temperature.
Choice B rationale
A temperature of 97.4°F (36.3°C) in a newborn is below the normal range (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increased oxygen consumption, and hypoglycemia. This newborn needs immediate assessment and warming measures to prevent complications.
Choice C rationale
A respiratory rate of 48 breaths per minute is within the normal range for a newborn (typically 30-60 breaths per minute). While the nurse will continue to monitor the respiratory status, this finding does not indicate immediate distress.
Choice D rationale
A pulse rate of 134 beats per minute is within the normal range for a newborn (typically 110-160 beats per minute). While the nurse will continue to monitor the cardiovascular status, this finding does not indicate immediate distress. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum involves significant fluid and electrolyte losses, but rapid plasma regain is not a specific indicator of this condition.
Choice B rationale
A urine culture is used to detect the presence of bacteria in the urine, typically to diagnose a urinary tract infection. While dehydration from hyperemesis gravidarum can increase the risk of a UTI, a urine culture is not a primary anticipated laboratory test for hyperemesis itself.
Choice C rationale
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. It is used to assess coagulation and is not directly related to the metabolic and electrolyte imbalances caused by hyperemesis gravidarum.
Choice D rationale
Urine ketones are a byproduct of fat breakdown for energy, which occurs when the body is not getting enough glucose. In hyperemesis gravidarum, persistent vomiting can lead to dehydration and starvation, forcing the body to break down fat for energy, resulting in ketonuria (ketones in the urine).
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum is characterized by severe nausea and vomiting leading to dehydration and electrolyte imbalances.
Choice B rationale
A urine culture is used to detect urinary tract infections, which are not a primary concern in hyperemesis gravidarum unless specifically indicated by symptoms of a UTI.
Choice C rationale
Prothrombin time (PT) and other coagulation studies assess blood clotting. While severe dehydration and malnutrition from hyperemesis gravidarum could theoretically affect coagulation, it is not a routine initial test to anticipate.
Choice D rationale
Urine ketones are a key laboratory finding in hyperemesis gravidarum. Due to persistent vomiting and inadequate oral intake, the body starts to break down fat for energy, leading to ketonuria. The presence of ketones in the urine indicates starvation and the need for intravenous fluids and nutritional support.
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