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
A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.
B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.
C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.
D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.
Correct Answer is ["E"]
Explanation
A. Place client in a negative pressure room: Negative pressure rooms are typically used for airborne precautions, not for preventing the transmission of HIV, which primarily requires standard precautions.
B. Implement droplet precautions: HIV does not spread through respiratory droplets. Droplet precautions are for diseases like influenza or meningitis that spread through respiratory droplets, not for HIV.
C. Encourage the mother to bottle-feed: This recommendation can vary based on specific circumstances. In many developed countries, the recommendation is for HIV-positive mothers to avoid breastfeeding to reduce the risk of transmitting HIV to the infant. However, this decision should be discussed with healthcare providers and based on individual circumstances.
D. Give antiviral medication intravenously: Antiretroviral medications are used to manage HIV. However, the method of administration and specific medications depend on the client's condition and the stage of pregnancy. Intravenous administration might not be the standard for HIV management during labor.
E. Use standard precautions: Standard precautions are the most appropriate approach. These include wearing gloves, practicing good hand hygiene, and using protective barriers as needed to prevent contact with blood and body fluids, which is the primary mode of HIV transmission.
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