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
Notifying the nursery about the client’s response is not an immediate intervention. It is more important to manage uterine contractions and fetal oxygenation before informing other departments about the client's condition.
Choice B rationale
Restarting the oxytocin infusion rate per protocol is necessary to resume labor induction. Oxytocin increases uterine contractions, promoting cervical dilation and progression of labor. Continuous monitoring is required to adjust the dosage.
Choice C rationale
Stopping oxygen per cannula is not recommended if fetal distress is present. Oxygen supplementation ensures adequate fetal oxygenation during uterine contractions, reducing the risk of hypoxia and related complications.
Choice D rationale
Checking for clonus in both feet is not relevant to the current scenario. Clonus is a neurological sign indicating hyperreflexia, often unrelated to labor management. The focus should be on managing uterine contractions and fetal well-being.
Correct Answer is C
Explanation
Choice A rationale
Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.
Choice B rationale
Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.
Choice C rationale
Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.
Choice D rationale
Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.
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