Nokea
Newborn, signs of diaphoresis, jitteriness, lethargy
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
- A. Obtain blood glucose by heel stick.
- B. Initiate phototherapy.
- C. Monitor the newborn's blood pressure.
- D. Place the newborn in a radiant warmer.
Correct Answer: A
Rationale: These symptoms suggest hypoglycemia, and obtaining a blood glucose level via heel stick is the priority to confirm and guide treatment.
You may also like to solve these questions
1-day-old newborn, indented anterior fontanelle
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
- A. Increased intracranial pressure.
- B. Vernix caseosa.
- C. Dehydration.
- D. Cyanosis.
Correct Answer: C
Rationale: An indented anterior fontanelle most likely indicates dehydration, as fluid loss causes the fontanelle to sink.
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.
Client at 40 weeks gestation, active labor, 6 cm cervical dilation, 100% effacement, blood pressure 82/52 mm Hg
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Assist the client to turn onto her side.
- B. Prepare for an immediate vaginal delivery.
- C. Prepare for a cesarean birth.
- D. Assist the client to an upright position.
Correct Answer: A
Rationale: Assisting the client to turn onto her side can improve blood flow to the placenta and increase fetal oxygenation, addressing hypotension which is a common cause of decreased uteroplacental perfusion.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
Newborn born 10 hours ago via cesarean section, moist lung sounds
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data?
- A. If this baby was born vaginally, it could indicate a pneumothorax.
- B. The neonate must have aspirated surfactant.
- C. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
- D. The nurse should notify the pediatrician stat for this emergency situation.
Correct Answer: C
Rationale: Babies born via cesarean section often have moist lung sounds due to retained fluid, as they miss the chest compression of vaginal delivery, and this typically resolves within 24 hours.