The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?

Obtain a drug screen for cocaine

Weigh and measure the newborn

Determine reactivity of neonatal reflexes

Perform gestational age assessment

Answer and Explanation

The Correct Answer is A

A. Obtain a drug screen for cocaine: Given the symptoms described (tremulous, tachycardic, hypertensive), there may be concern about drug exposure, and cocaine is a substance known to cause such symptoms in newborns. Therefore, obtaining a drug screen for cocaine is a reasonable and important action to determine if there was prenatal exposure.

B. Weigh and measure the newborn: While weighing and measuring the newborn is a routine part of the newborn assessment, it may not be the most crucial action in this context. The symptoms described suggest the need for a more immediate assessment related to possible drug exposure.

C. Determine reactivity of neonatal reflexes: Assessing the reactivity of neonatal reflexes is an important part of the newborn assessment, but in this specific situation, the symptoms described (tremulous, tachycardic, hypertensive) may warrant a more focused and immediate assessment related to drug exposure.

D. Perform gestational age assessment: Gestational age assessment is essential for understanding the newborn's maturity and adjusting care accordingly. However, in this scenario, the immediate concern seems to be the symptoms the newborn is presenting with, and addressing the possibility of drug exposure takes precedence.

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Correct Answer is C

Explanation

A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.

B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.

C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.

D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.

A. Level of pain sensation. B. Variability of fetal heart rate C. Maternal blood pressure D. Station of presenting part

Correct Answer is C

Explanation

Level of pain sensation:

This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.

Variability of fetal heart rate:

Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.

Maternal blood pressure:

This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.

Station of presenting part:

The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.

What Is An Adverse Effect Of Epidural Anesthesia

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The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Correct Answer is C

Explanation

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