A nurse receives handoff report. Which newborn should the nurse assess first?
Glucose reading 58 mg/dL.
Pulse 144 beats/minute.
Respiratory rate 78 breaths/minute.
Temperature 97.7° F (36.5° C).
The Correct Answer is A
Choice A reason:
Pulse rate of 144 beats per minute is within the normal range for a newborn, which can range from 120 to 160 beats per minute. While it is essential to monitor the pulse rate, it does not require immediate intervention.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Temperature of 97.7° F (36.5° C) is slightly below the normal range for a newborn's temperature, which is typically around 98.6° F (37° C). While temperature assessment is crucial, it does not demand immediate attention compared to other more critical aspects.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Assisting the client into a comfortable position (Choice A) might be appropriate in some labor scenarios, but in this case, the client's sudden urge to push indicates that the baby's birth is imminent. Therefore, the nurse should focus on evaluating the stage of labor and preparing for delivery rather than repositioning the client.
Choice B reason:
Observing for crowning is essential, but it should be done after addressing the client's immediate urge to push. Crowning indicates that the baby is very close to being born, but at 7 cm dilation, the client is not yet in the second stage of labor where pushing is appropriate.
Choice C reason:
Panting helps the client manage the urge to push and prevents premature pushing, which can cause cervical swelling or injury. This technique helps delay pushing until full dilation is achieved, ensuring a safer delivery process.
Choice D reason:
Helping the client to the bathroom to void (Choice D) is not advisable at this point. The client's urge to push indicates that the baby is descending, and birth is imminent. It would not be safe to have the client walk to the bathroom at this stage, as she may deliver the baby during the process, increasing the risk of an unattended birth.
Correct Answer is B
Explanation
Choice A reason:
Inspecting if the urethral opening appears circular. This is a correct action for the nurse to do, as it helps to identify any abnormalities in the urethral opening, such as hypospadias or epispadias, which are congenital defects where the opening is located on the underside or the top of the penis, respectively. • Choice B reason:
Retracting the foreskin over the glans to assess for secretions. This is an incorrect action for the nurse to avoid, as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans in newborns and should not be forcibly retracted. It will gradually loosen over time and can be retracted by the child himself when he is older. •
Choice C reason:
Palpating if testes are descended into the scrotal sac. This is a correct action for the nurse to do, as it helps to detect any undescended testes, which are more common in preterm infants and can increase the risk of infertility and testicular cancer later in life. • Choice D reason:
Inspecting the genital area for irritated skin. This is a correct action for the nurse to do, as it helps to identify any signs of diaper rash, fungal infection, or allergic reaction in the newborn's skin.
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