Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Obtain a capillary glucose level.

Feed 30 mL of 10% dextrose in water.

Wrap tightly in a blanket.

Encourage the mother to breastfeed.

Answer and Explanation

The Correct Answer is A

Choice A: Obtain a capillary glucose level. This is the first action that the nurse should do, as it can diagnose hypoglycemia, which is a low blood sugar level that can cause jitteriness and tachypnea in newborns. Hypoglycemia can be caused by maternal diabetes, prematurity, infection, or delayed feeding. The nurse should check the glucose level using a heel stick and a glucometer.

Choice B: Feed 30 mL of 10% dextrose in water. This is not the first action that the nurse should do, as it may not be appropriate for all newborns with jitteriness and tachypnea. Feeding 10% dextrose in water can raise the blood sugar level, but it may also cause rebound hypoglycemia or fluid overload. The nurse should feed only after confirming hypoglycemia and obtaining a healthcare provider's order.

Choice C: Wrap tightly in a blanket. This is not the first action that the nurse should do, as it may not address the underlying cause of jitteriness and tachypnea in newborns. Wrapping tightly in a blanket can prevent heat loss and conserve energy, but it may also impair breathing or circulation. The nurse should wrap only after ruling out other causes of jitteriness and tachypnea.

Choice D: Encourage the mother to breastfeed. This is not the first action that the nurse should do, as it may not be feasible or effective for all newborns with jitteriness and tachypnea. Breastfeeding can provide nutrition and bonding for newborns, but it may also be difficult or contraindicated for some newborns with respiratory distress or infection. The nurse should encourage breastfeeding only after assessing and stabilizing the newborn's condition.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect because seizure precautions are not indicated for dopamine administration. Dopamine does not lower the seizure threshold or cause convulsions.

Choice B reason: This is incorrect because monitoring serum potassium frequently is not necessary for dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia.

Choice C reason: This is correct because ensuring pump accuracy to prevent toxicity is essential for dopamine administration. Dopamine is a potent vasoconstrictor that can cause tissue necrosis, gangrene, and hypertension if overdosed.

Choice D reason: Dopamine is given to hypotensive patients, meaning they may be weak, dizzy, or at risk of falls.Ambulating frequently could worsen hypotension and increase fall risk rather than help the patient. Instead, the nurse should monitor the patient’s hemodynamic status and ensure bed rest as needed until blood pressure stabilizes.

A. Client’s healthcare power of attorney. B. Currently prescribed medications. C. Fall at home as reason for admission. D. Increasing confusion of the client.

Correct Answer is D

Explanation

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

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Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who is hypotensive is receiving dopamine, an adrenergic agonist IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement when administering this medication?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

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