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 C
Explanation
Choice A rationale:
Iron is crucial for the development of hemoglobin, which carries oxygen to all parts of the body, including the bones, but it does not directly facilitate bone growth.
Choice B rationale:
While newborns do metabolize iron, their iron stores are limited, and breast milk alone may not meet their iron needs.
Choice C rationale:
When educating a parent about the use of iron-fortified formula for their newborn, it is essential to convey that newborns have a limited store of iron, which begins to deplete around the age of 6 months.
Choice D rationale:
Iron facilitating eyesight development is not a relevant aspect to consider when discussing the use of iron-fortified formula for a newborn. While iron is essential for various physiological functions, it is not specifically linked to eyesight development.
Correct Answer is A
Explanation
Choice A rationale:
Placing the newborn in an incubator is essential because the newborn's temperature control mechanism is immature. Premature infants have an underdeveloped thermoregulatory system, making them susceptible to heat loss and cold stress. An incubator provides a controlled, warm environment to maintain the newborn's body temperature within the normal range (around 36.5°C to 37.5°C or 97.7°F to 99.5°F).
Choice B rationale:
Heat increasing the flow of oxygen to the newborn's extremities is not a valid reason for placing the newborn in an incubator. Oxygenation is primarily influenced by respiratory and circulatory mechanisms, not external heat.
Choice C rationale:
The newborn's small body surface area for his weight is not directly related to the need for an incubator. Premature infants have a higher surface area to weight ratio, making them more prone to heat loss, but this is not the primary reason for using an incubator.
Choice D rationale:
Heat facilitating the drainage of mucus is not a reason for placing the newborn in an incubator. Proper positioning and suctioning are used to manage mucus in premature infants, but incubators are primarily for temperature regulation.
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