The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority?
Select one:

Obtain a bilirubin level.

Place a pulse oximeter on the newborn.

Obtain a blood glucose level.

Take the newborn's vital signs.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.

Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.

Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and eﬀectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.

Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.

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Correct Answer is B

Explanation

Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a diﬀerent reﬂex called the rooting reﬂex. The rooting reﬂex is a feeding reﬂex that helps the newborn locate the nipple and initiate sucking. The rooting reﬂex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.

Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reﬂex, which is a primitive reﬂex that is present at birth and disappears by 3 to 6 months of age. The Moro reﬂex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reﬂex consists of four phases: extension, abduction, adduction, and crying.

Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reﬂex called the tonic neck reﬂex. The tonic neck reﬂex is a postural reﬂex that helps prepare the newborn for voluntary reaching. The tonic neck reﬂex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm ﬂexed.

Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a diﬀerent reﬂex called the Babinski reﬂex. The Babinski reﬂex is a neurological reﬂex that tests for spinal cord integrity. The Babinski reﬂex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiﬂex and the other toes to fan out.

A. Milia. B. Dermal melanosis. C. Stork bites. D. Birth trauma.

Correct Answer is B

Explanation

Choice A Reason: Milia. This is an incorrect answer that describes a diﬀerent skin condition. Milia are tiny white or yellow cysts that appear on the nose, chin, or cheeks of newborns. They are caused by the retention of keratin in the sebaceous glands or hair follicles. They usually disappear within a few weeks without treatment.

Choice B Reason: Dermal melanosis. This is a correct answer that explains the finding of bluish markings across the newborn's lower back. Dermal melanosis. This is because dermal melanosis, also known as Mongolian spots, is a common benign skin condition that aﬀects newborns of Asian, African, or Hispanic descent. It is characterized by bluish-gray or brown patches of pigmentation on the lower back, butocks, or extremities. It is caused by the migration of melanocytes from the neural crest to the dermis during embryonic development. It usually fades by 2 to 4 years of age.

Choice C Reason: Stork bites. This is an incorrect answer that refers to another skin condition. Stork bites, also known as salmon patches or nevus simplex, are ﬂat pink or red marks that appear on the forehead, eyelids, nose, upper lip, or nape of the neck of newborns. They are caused by dilated capillaries in the superficial dermis. They usually fade by 18 months of age.

Choice D Reason: Birth trauma. This is an incorrect answer that implies an injury or damage to the newborn's skin or tissues during labor and delivery. Birth trauma can cause bruises, abrasions, lacerations, fractures, or nerve injuries. It is not related to bluish markings on the lower back.

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The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority? Select one:

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Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority?
Select one: