The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
Monitor temperature.
Continue to monitor glucose levels.
Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
Tell the mother that she will need to discuss any concerns with the neonatologist.
Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer : A,B,C,D
Choice A rationale
Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.
Choice B rationale
Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.
Choice C rationale
Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.
Choice D rationale
Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Collecting a urine sample for dipstick analysis can identify urinary tract infections (UTIs) or other abnormalities. Dipstick tests detect leukocytes, nitrites, protein, and glucose, providing rapid results for initial screening of urinary issues.
Choice B rationale
Asking the client if she had sexual intercourse yesterday may help identify potential causes of urinary frequency, such as post-coital irritation. However, it does not directly address the irregular uterine contractions or possible infections.
Choice C rationale
Obtaining a midstream urine specimen for culture is crucial for diagnosing UTIs, which can cause urinary frequency and uterine irritability. Culturing urine identifies specific pathogens, guiding targeted antibiotic therapy to treat the infection.
Choice D rationale
Determining if she has a change in vaginal discharge can indicate infections or other conditions affecting the reproductive tract. However, it does not directly address the urinary frequency or irregular uterine contractions, making it less immediate.
Correct Answer is A
Explanation
Choice A rationale
Hydralazine decreases blood pressure by vasodilation, improving renal perfusion and function. Enhanced kidney function promotes diuresis, balancing fluid levels and reducing hypertension.
Choice B rationale
While controlling blood pressure indirectly benefits liver health, hydralazine's primary effect on vasodilation does not directly support liver function.
Choice C rationale
Hydralazine primarily lowers blood pressure through vasodilation. Preventing arrhythmias is more directly associated with medications affecting cardiac conduction rather than vasodilators.
Choice D rationale
Lowering cholesterol levels is not a direct effect of hydralazine. Its primary action is reducing blood pressure through vascular smooth muscle relaxation, decreasing hypertension.
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