The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?
A. Hypoglycemia.
Polycythemia.
Hyperthermia.
Hyperbilirubinemia.
None
None
The Correct Answer is A
Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.
Choice B rationale
Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.
Choice C rationale
Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.
Choice D rationale
Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Step 1 is (2 grams/hour ÷ 20 grams) × 500 mL.
Step 2 is (2 ÷ 20) × 500.
Step 3 is 0.1 × 500. The final calculated answer is 50 mL/hour.
Correct Answer is B
Explanation
Choice B rationale
Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.
Choice A rationale
Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.
Choice C rationale
Contacting the obstetrician is also important but comes after informing the anesthesia care provider.
Choice D rationale
Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.
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