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 D
Explanation
Choice A rationale:
"He is just cold”. is not the correct choice. While newborns can have cold hands and feet due to their immature thermoregulation, it would not explain persistent blue hands.
Choice B rationale:
"He may have been born with a heart problem”. is not the correct choice as it suggests a congenital heart defect. While cyanosis (bluish discoloration) can be associated with some heart problems, the hands alone being blue is less likely to be solely related to a heart issue.
Choice C rationale:
"The hands are always blue in a newborn”. is not the correct choice. While newborns may have bluish extremities (acrocyanosis) during the first few days after birth due to their developing circulatory system, persistent blue hands beyond this period would require further assessment.
Choice D rationale:
The correct choice is that "The circulation in his hands is not fully developed.”. Newborns have a developing circulatory system, and sometimes, their peripheral circulation takes some time to mature, leading to transient blue hands. However, if the blue color persists or worsens, it's essential to evaluate for any underlying issues.
Correct Answer is A
Explanation
Choice A rationale:
The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.
Choice B rationale:
Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.
Choice C rationale:
Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.
Choice D rationale:
Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.
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