Assessment findings of a 4-hour-old newborn include: 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, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
Document the findings in the record
Obtain a heel stick blood glucose level.
Place a pulse oximeter on the heel.
Swaddle the infant in a warm blanket
The Correct Answer is B
A. Document the findings in the record: Documenting the findings is important, but it doesn't address the potential issue of hypoglycemia.
B. Obtain a heel stick blood glucose level: This is the most appropriate action given the signs presented. A low blood glucose level can be a critical issue in newborns and requires prompt evaluation and management.
C. Place a pulse oximeter on the heel: While oxygen saturation monitoring is valuable in certain situations, it may not be the priority in this case where hypoglycemia is suspected.
D. Swaddle the infant in a warm blanket: While maintaining warmth is important, especially if the baby is hypothermic, addressing the potential hypoglycemia takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.
Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.
Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.
Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.
Correct Answer is C
Explanation
A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.
B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.
C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.
D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.
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