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.

Answer and Explanation

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. .

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Correct Answer is D

Explanation

Choice A rationale

Obtaining consent for the Hepatitis B vaccine is a necessary step in the newborn's care, but it is not the immediate priority for a newborn exposed to HIV. The focus should be on preventing HIV transmission from mother to child.

Choice B rationale

Collecting a venous specimen for serum glucose level is important for assessing the newborn's metabolic status, but it does not directly address the immediate need to reduce the risk of HIV transmission.

Choice C rationale

Assessing for the presence of the Moro reflex is part of a routine newborn examination and is important for evaluating the neurological status of the newborn. However, it does not address the immediate priority of HIV prophylaxis.

Choice D rationale

Ensuring that zidovudine is given within 6 hours after birth is critical for reducing the risk of mother-to-child transmission of HIV. Early administration of antiretroviral medication is essential to prevent viral replication and transmission to the newborn.

A. Use standard precautions. B. Give antiviral medication intravenously. C. Implement droplet precautions. D. Encourage the mother to bottle-feed. E. Place client in a negative pressure room.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Standard precautions should always be used to prevent the transmission of infections. This includes wearing gloves, gowns, and masks when necessary to protect both the healthcare provider and the patient.

Choice B rationale

Antiviral medication is critical for an HIV-positive mother in labor to reduce the risk of vertical transmission of the virus to the newborn. Intravenous administration ensures rapid delivery and effective drug levels.

Choice C rationale

Droplet precautions are not necessary for HIV as the virus is not transmitted via droplets. It is primarily transmitted through blood, sexual contact, and from mother to child during childbirth or breastfeeding.

Choice D rationale

Bottle-feeding is encouraged for HIV-positive mothers to prevent postnatal transmission of the virus through breast milk. Breastfeeding can increase the risk of the infant contracting HIV.

Choice E rationale

Negative pressure rooms are used for airborne diseases like tuberculosis, not for HIV. HIV is not airborne, so standard precautions suffice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

Correct Answer is D

Explanation

A client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive.Which action(s) should the nurse plan to perform? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.