Nokea
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
You may also like to solve these questions
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Cries vigorously when stimulated
- B. A positive Babinski reflex
- C. Heart rate of 220 beats/minute
- D. Flexion of all four extremities
Correct Answer: A
Rationale: Vigorous crying indicates effective breathing and responsiveness, key signs of successful transition to extrauterine life.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Schedule an appointment for the client with the diabetic nurse educator.
- B. Counsel her to increase her caloric intake
- C. Inform her that a decreased need for insulin occurs while breastfeeding
- D. Advise the client to breastfeed more frequently
Correct Answer: C
Rationale: Breastfeeding can lower insulin requirements due to increased energy expenditure, and informing the client of this normal change is appropriate.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Monitor blood pressure pulse, and respirations every 4 hour
- B. Keep an airway at the bedside
- C. Allow liberal family visitation
- D. Assess temperature every hour
Correct Answer: B
Rationale: Eclampsia can lead to seizures, making airway management equipment critical to ensure safety during a potential seizure event.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
- A. Bleeding tendencies
- B. Heat loss
- C. Hypoglycemia
- D. Fluid balance
Correct Answer: B
Rationale: Newborns are at high risk for hypothermia due to heat loss, which can compromise survival. Preventing heat loss is a priority immediately after birth.
The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?
- A. Request a return demonstration of a diaper change
- B. Evaluate infant feeding techniques prior to discharge
- C. Provide the results of the infant's hearing test to the parents.
- D. Ensure that they have the pediatric clinic's phone number
Correct Answer: B
Rationale: Proper feeding techniques are critical for the infant's nutrition and growth, making evaluation of these skills the priority before discharge.