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 C
Explanation
A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.
B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.
C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.
D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.
Correct Answer is A
Explanation
A. Strawberries:
Strawberries contain a moderate amount of folic acid, providing a good alternative source for the client. While not as high as some vegetables, they still offer a reasonable amount of this essential nutrient. This could be a suitable option considering the client's dislike for green leafy vegetables and allergy to soy.
B. Collard greens:
Collard greens are an excellent source of folic acid. However, since the client dislikes green leafy vegetables, recommending collard greens might not align with her preferences.
C. Whole milk:
Whole milk doesn't contain significant amounts of folic acid. While it's a source of other nutrients, it isn't a primary choice for obtaining folic acid.
D. Yogurt:
Similar to whole milk, yogurt doesn't contain a substantial amount of folic acid. While it offers various health benefits due to its probiotics and nutrients, it's not a significant source of folic acid.
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