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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The diaphragm must be refitted after childbirth:
This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.
The most effective form of contraception is a diaphragm:
This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.
The diaphragm should be inserted 2 to 4 hours before intercourse:
This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.
Vaseline lubricant can be used when inserting the diaphragm:
This statement is incorrect. Oil-based lubricants, including Vaseline, can damage latex diaphragms. Water-based lubricants are recommended for use with diaphragms
Correct Answer is D
Explanation
A. Place the newborn in a position with the head lower than the feet:
This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares:
Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change:
Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back:
This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
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