A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?
Place the newborn in a radiant warmer.
Initiate phototherapy.
Obtain blood glucose by heel stick.
Measure the newborn's blood pressure.
The Correct Answer is C
Choice A rationale:
Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.
Choice B rationale:
Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.
Choice C rationale:
The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.
Choice D rationale:
Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Newborns do not show interest in eating while crying. Crying is usually an indication of distress or hunger and not a state where they are interested in eating.
Choice B rationale:
Newborns are most interested in eating when they are in an "alert”. state. During this state, the baby is awake, calm, and attentive, making it an ideal time for feeding.
Choice C rationale:
In the "drowsy”. state, newborns may be sleepy and less interested in eating. They might feed less effectively in this state.
Choice D rationale:
"Active alert”. is a state where the newborn is awake, attentive, and active. While they may be interested in their surroundings, they may also be easily distracted during feeding.
Correct Answer is C
Explanation
Choice A rationale:
The liver's job related to bilirubin is not changing conjugated bilirubin to unconjugated. Conjugated bilirubin is the water-soluble form of bilirubin that is excreted in bile and urine. Unconjugated bilirubin, on the other hand, is the fat-soluble form, which is transported to the liver and conjugated to become water-soluble. The conversion goes from unconjugated to conjugated, not the other way around.
Choice B rationale:
The liver's job related to bilirubin is not the synthesis of vitamin K. The liver is responsible for synthesizing clotting factors, including factors II (prothrombin), VII, IX, and X, but not vitamin K itself. Vitamin K is obtained from dietary sources or supplements and is essential for blood clotting.
Choice C rationale:
This choice is the correct answer. The liver's primary function related to bilirubin is changing unconjugated bilirubin to conjugated bilirubin. As mentioned earlier, unconjugated bilirubin is produced from the breakdown of heme in old red blood cells, and it needs to be processed in the liver to become water-soluble and eventually excreted in bile and urine.
Choice D rationale:
The liver's job related to bilirubin does not involve the removal of meconium. Meconium is the first stool passed by a newborn, and its elimination is unrelated to the liver's function in processing bilirubin.
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