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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.
Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.
Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.
Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer.According to the rule of nines, each leg accounts for 18% of the total body surface area, and the anterior surface of each leg accounts for half of that, or 9%. Therefore, the patient has partial-thickness burns on 9% + 9% = 18% of the body surface area.
Choice B reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, as well as the head and neck, which is not given in the question.
Choice C reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior surface of only one leg, which is not given in the question.
Choice D reason: This is incorrect. This would be the case if the patient had partial-thickness burns on the anterior and posterior surfaces of both legs, which is not given in the question.
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