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

Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.

Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.

Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.

Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.

A. Sleep deprivation. B. Fluid volume excess C. Nausea and vomiting D. Risk for infection.

Correct Answer is B

Explanation

A. Sleep deprivation:

While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.

B. Fluid volume excess:

Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.

C. Nausea and vomiting:

While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.

D. Risk for infection:

Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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