The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?
Metabolic alkalosis.
Metabolic acidosis.
The infant is hungry.
The infant is overstimulated.
The Correct Answer is B
A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.
B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.
C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.
D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice B rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice C rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice D rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
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.
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