Assessment findings of a 4-hour-old newborn include an axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and a weak cry.
Based on these findings, which action should the nurse implement?
Obtain a heel stick blood glucose level.
Swaddle the infant in a warm blanket.
Place a pulse oximeter on the heel.
Document the findings in the record.
The Correct Answer is A
Choice A rationale
The symptoms of jitteriness, hypotonia, weak cry, and low temperature can indicate hypoglycemia in a newborn. Obtaining a heel stick blood glucose level is crucial to confirm the diagnosis and provide appropriate treatment.
Choice B rationale
While keeping the infant warm is important, it does not address the underlying issue of potential hypoglycemia, which needs to be identified and treated promptly.
Choice C rationale
Placing a pulse oximeter on the heel assesses oxygen saturation, which is not directly related to the symptoms described. The primary concern here is glucose level, not oxygen saturation.
Choice D rationale
Documenting the findings is important but does not provide immediate intervention for potential hypoglycemia, which requires urgent glucose level assessment and treatment if necessary. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Providing multidisciplinary resources and ongoing support is crucial for newborns exposed to methadone. This approach helps in managing withdrawal symptoms and ensures the child receives comprehensive care.
Choice A rationale
Keeping the newborn in the nursery may be beneficial initially but does not address the long-term needs of the child and the family.
Choice C rationale
Administering methadone to the newborn is not typically done unless specifically indicated by the healthcare provider.
Choice D rationale
Calling social services for foster care placement may be necessary in some cases, but providing support and resources to the mother and child is the primary intervention.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.
Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.
Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.
Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.
Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.
Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.
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