The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. What is the nurse's priority action?

Notifying the provider immediately.

Pressing on the bladder to prevent urine retention.

Administering IV fluid.

Documenting and continuing monitoring.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Notifying the provider immediately may be an appropriate action in certain urgent situations. However, for a newborn who has not voided for the first time yet, it is not an immediate emergency. The priority is to assess the newborn's condition further before notifying the provider.

Choice B rationale:

Pressing on the bladder to prevent urine retention is not a recommended action. Applying pressure on the newborn's bladder can be harmful and is not a standard nursing practice.

Choice C rationale:

Administering IV fluid is not the priority action for a newborn who has not voided. Newborns usually receive sufficient hydration from breastfeeding or formula feeding, and administering IV fluid without proper indication can lead to potential complications.

Choice D rationale:

Documenting and continuing monitoring is the correct priority action in this situation. Newborns often take some time to pass their first urine, and it is considered normal for them to have delayed voiding within the first 24 hours after birth. The nurse should document the absence of voiding and monitor the newborn for any signs of distress or abnormalities. If the newborn's condition worsens or if there are other concerning symptoms, then notifying the provider may be necessary.

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Correct Answer is B

Explanation

Choice A rationale:

The nurse should not report the client's Hemoglobin level first to the primary health care because it falls within the normal range of 14 to 24 g/dL for a newborn. Therefore, it is not an immediate concern.

Choice B rationale:

The nurse should first report the client's Chest x-ray results to the primary health care. The diffuse pattern of radiopaque areas bilaterally on the chest x-ray suggests possible respiratory distress or other respiratory issues in the newborn. This finding requires immediate attention and intervention to ensure proper respiratory function.

Choice C rationale:

The nurse should not report the client's Glucose level first to the primary health care as 40 mg/dL is within the normal range of 30 to 60 mg/dL for a newborn. Though it is on the lower side, it is not critically low, and there are more urgent concerns to address.

A. The nurse should first report the client's laboratory results to the primary health care. B. The nurse should first report the client's respiratory status to the primary health care. C. The nurse should first report the client's brachial pulses to the primary health care.

Correct Answer is B

Explanation

The nurse should first report the client's respiratory status to the primary health care.

Choice A rationale:

Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.

Choice B rationale:

Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.

Choice C rationale:

Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.

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The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation. Exhibits Which action should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn. Which of the following statements by the parent indicates a need for further teaching?

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.).

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?