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:
The fit of the newborn's clothes is not a reliable indicator of hydration. It may vary based on the clothing size or style and does not give a direct measure of the newborn's hydration status. This choice is not appropriate for evaluating hydration and is therefore incorrect.
Choice B rationale:
The number of wet diapers per day is an essential measure for assessing a newborn's hydration. In the first few days after birth, the baby should have at least one wet diaper for each day of life (e.g., one wet diaper on day one, two on day two, etc.). Afterward, the newborn should have around 6-8 wet diapers per day, which indicates adequate hydration. This choice is appropriate and the correct answer.
Choice C rationale:
How often the newborn cries can be influenced by various factors, including hunger, discomfort, or sleepiness. While crying can indicate the baby's needs, it is not a specific or accurate measure of hydration status. Therefore, this choice is not appropriate for evaluating hydration and is incorrect.
Choice D rationale:
The newborn's skin turgor is a measure of skin elasticity, commonly used in adults to assess hydration. However, it is not a reliable indicator of hydration in newborns, as their skin is more elastic and different from adult skin. Skin turgor is not a suitable parameter to evaluate newborn hydration, making this choice incorrect.
Correct Answer is D
Explanation
Choice A rationale:
15 mL is not the correct choice because it only considers the first two feedings and does not account for the intake during the entire shift.
Choice B rationale:
30 mL is not the correct choice because it only considers the first three feedings and does not account for the intake during the entire shift.
Choice C rationale:
45 mL is not the correct choice because it only considers the first four feedings and does not account for the intake during the entire shift.
Choice D rationale:
The nurse should record 60 mL of formula as the newborn's intake for the shift. To calculate the total intake, you add the amounts from each feeding: 0.5 oz + 1 oz + 0.5 oz + 0.5 oz + 0.5 oz = 60 mL. Remember that 1 fluid ounce (oz) is approximately equal to 30 mL.
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