Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
Obtain a heel stick blood glucose level.
Document the findings in the record.
Swaddle the infant in a warm blanket.
Place a pulse oximeter on the heel.
The Correct Answer is A
Choice A rationale
A heel stick blood glucose test is crucial for an infant showing jitteriness, hypotonicity, and weak cry as these symptoms suggest hypoglycemia which requires immediate confirmation and treatment.
Choice B rationale
Documenting findings is essential but does not address the immediate need to rule out and treat hypoglycemia in the symptomatic newborn.
Choice C rationale
Swaddling the infant provides comfort and warmth but does not address potential hypoglycemia, which is the priority in this case.
Choice D rationale
Placing a pulse oximeter monitors oxygenation but does not directly address the underlying cause of jitteriness and hypotonia, which could be hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Shallow and irregular respirations are normal for newborns and do not typically indicate respiratory distress. Regular assessment is necessary to determine if there is an underlying issue.
Choice B rationale
Flaring of the nares is a sign of increased effort to breathe and is an indication of respiratory distress in newborns. This symptom requires immediate attention to address potential underlying conditions.
Choice C rationale
Abdominal breathing with synchronous chest movement is normal in newborns due to their diaphragmatic breathing pattern. It does not indicate respiratory distress unless other symptoms are present.
Choice D rationale
A respiratory rate of 50 breaths per minute is within the normal range for newborns (30-60 breaths per minute). This does not indicate respiratory distress unless accompanied by other abnormal signs.
Correct Answer is A
Explanation
Choice A rationale
Passive immunity provided by maternal antibodies crossing the placenta and through breast milk protects newborns in the first months of life, offering initial defense against communicable diseases.
Choice B rationale
Antiinfectants effectiveness against microbes does not apply; newborns rely on passive immunity as their adaptive immune system matures, not unresistant antiinfectants.
Choice C rationale
Active immunity develops over several months to years in newborns, as their immune system gradually encounters pathogens and develops specific responses.
Choice D rationale
While neutrophils are part of the innate immune system, they may still be immature and insufficient in preventing infections in neonates without maternal antibody support.
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