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 B
Explanation
Choice A rationale
Edema, particularly peripheral edema, is a common clinical sign of preeclampsia. It results from fluid shifts due to increased vascular permeability and decreased plasma protein levels associated with the disease process.
Choice B rationale
Glycosuria, the presence of glucose in the urine, is not typically a symptom of preeclampsia. It is more commonly associated with gestational diabetes, a separate condition of pregnancy characterized by impaired glucose tolerance.
Choice C rationale
Proteinuria, the presence of significant amounts of protein in the urine (typically ≥300 mg in a 24-hour urine collection), is a hallmark sign of preeclampsia. It reflects glomerular endothelial damage and increased permeability.
Choice D rationale
Hypertension, defined as a blood pressure of ≥140/90 mmHg on two separate occasions at least 4 hours apart after 20 weeks of gestation, is a key diagnostic criterion for preeclampsia. It results from systemic vasoconstriction.
Correct Answer is C
Explanation
Choice A rationale
Limiting the newborn's intake of milk is contraindicated in the treatment of hyperbilirubinemia. Adequate hydration and frequent feedings are essential to promote bilirubin excretion through stool and urine. Decreased intake can exacerbate dehydration and worsen jaundice. Normal feeding frequency for newborns is typically every 2-3 hours.
Choice B rationale
Feeding the newborn every six hours is not an appropriate intervention for a jaundiced infant receiving phototherapy. Frequent feedings, typically every 2-3 hours, are necessary to promote bilirubin excretion. Prolonged intervals between feedings can lead to dehydration and hinder the effectiveness of phototherapy.
Choice C rationale
Turning the infant every two hours is a crucial nursing intervention during phototherapy. This ensures that all body surfaces are exposed to the ultraviolet light, maximizing the breakdown of bilirubin in the skin. Consistent exposure of all areas helps to lower bilirubin levels more effectively.
Choice D rationale
Applying an oil-based lotion to the newborn's skin during phototherapy is contraindicated. Oil-based lotions can create a barrier on the skin, reducing the penetration and effectiveness of the ultraviolet light. Only water-based lotions, if necessary, should be used sparingly and with caution, as some may absorb UV light.
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