Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

Respiratory distress.

Hyperglycemia.

Metabolic alkalosis.

Hypoglycemia.

Answer and Explanation

Correct Answer : A,D

Choice A rationale:

Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.

Choice B rationale:

Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.

Choice C rationale:

Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.

Choice D rationale:

Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.

Choice E rationale:

Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.

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Correct Answer is C

Explanation

Choice A rationale:

Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.

Choice B rationale:

Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.

Choice C rationale:

The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.

Choice D rationale:

Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.

A. Document this as an expected finding. B. Call the neonatologist to assess the newborn. C. Ask another nurse to verify the heart rate. D. Prepare the newborn for transport to the NICU.

Correct Answer is A

Explanation

Choice A rationale:

An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.

Choice B rationale:

Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.

Choice C rationale:

Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.

Choice D rationale:

Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.

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Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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