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.
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Related Questions
Correct Answer is C
Explanation
A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.
B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.
C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.
D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.
Correct Answer is ["12"]
Explanation
To solve this problem, the nurse needs to convert the units of oxytocin from units to milliunits.
One unit of oxytocin is equal to 1000 milliunits, so 10 units of oxytocin is equal to 10,000 milliunits.
- The concentration of oxytocin in the solution is 10,000 milliunits per 1000 mL, or 10 milliunits per mL.
- To deliver 2 milliunits per minute, the nurse needs to infuse 0.2 mL per minute of the solution.
- To convert from mL per minute to mL per hour, the nurse needs to multiply by 60 minutes per hour.
- Therefore, the nurse should program the infusion pump to deliver 0.2 x 60 = 12 mL per hour of the solution.
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