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 D
Explanation
Choice A rationale
Yogurt is a good source of calcium and protein but is not particularly high in folic acid. It is beneficial for overall health but not the best option for increasing folic acid intake.
Choice B rationale
Collard greens are high in folic acid, but since the client does not like green leafy vegetables, this option is not suitable for her.
Choice C rationale
Whole milk provides vitamin D and calcium, but it is not a significant source of folic acid. It would not effectively help the client meet her increased folic acid needs.
Choice D rationale
Strawberries are a good source of folic acid and can be a suitable option for the client to increase her intake without consuming green leafy vegetables or soy products. .
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.
Choice B rationale
Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.
Choice C rationale
Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.
Choice D rationale
Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.
Choice E rationale
Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.
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