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 ["B","C","D","E"]

Explanation

Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.

Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.

Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.

Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.

Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.

A. Monitor indwelling urinary catheter and measure strict intake and output. B. Keep the bed in the lowest position and initiate seizure and fall precautions. C. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Maintain elevated positioning of the dependent joints on affected side.

Correct Answer is C

Explanation

Choice A: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.

Choice B: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.

Choice C: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA., which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.

Choice D: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.

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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

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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