A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?

Feed the infant at least 1 ounce of formula.

Collect a sterile urine specimen to evaluate for drugs of abuse.

Swaddle the infant with hands near its mouth.

Move the infant into a brightly lit area for further assessment.

Answer and Explanation

The Correct Answer is C

A. Feed the infant at least 1 ounce of formula: Feeding may help if the baby is hungry, but it is not the first action in managing symptoms of NAS.
B. Collect a sterile urine specimen: This is an important step for diagnosing NAS but is not the immediate action to calm the infant.
C. Swaddle the infant with hands near its mouth: These symptoms are consistent with neonatal abstinence syndrome (NAS). Comfort measures such as swaddling and non-nutritive sucking are prioritized to soothe the infant.
D. Move the infant into a brightly lit area: A quiet, dim environment is better for soothing an overstimulated baby, so this action would be counterproductive.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Delayed diaper changes can increase the risk of skin breakdown and infection.
B. Frequent repositioning and stimulation with a mobile may increase stress and intracranial pressure.
C. Minimizing stimulation, providing boundaries, and maintaining a calm environment (e.g., dim lighting) help reduce intracranial pressure and prevent further bleeding in infants with periventricular hemorrhage.
D. While pain management is important, feeding increases may exacerbate intracranial pressure and are not the priority.

A. Basal metabolic rate reduction B. Cold stress C. Shivering D. Brown fat production

Correct Answer is B

Explanation

A. The basal metabolic rate may increase as a result of cold stress, but the primary purpose of the warmer is to prevent cold stress.
B. Newborns are at risk of cold stress because they have a large body surface area and limited ability to regulate body temperature. A radiant warmer is used to help maintain the newborn’s body temperature and prevent cold stress.
C. Newborns do not typically shiver to generate heat. They rely on mechanisms such as non-shivering thermogenesis (use of brown fat).
D. Brown fat is used for heat production, but the goal of the radiant warmer is to prevent cold stress, not directly stimulate brown fat production.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?

Correct Answer is C

Explanation

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

Correct Answer is B

Explanation

A 1-day old newborn was born to a mother who had positive vaginal cultures for Group Beta Strep. The mother was only in labor for 1 hour prior to birth. What findings would indicate possible neonatal sepsis?

Newborn heat loss through evaporation can be reduced by:

The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?

A mother is concerned about her 3-day-old breastfeeding newborn whose birth weight was 2678g and is now 2505g. What is the most appropriate response by the nurse?

The nurse is assessing a 1-day old neonate and notes white raised spots on the baby's nose. What is the priority response?

A nurse admitted a neonate born less than 2 hours ago to a mother with gestational diabetes. The neonate weighs 4.5 kg. What is the priority nursing action for this neonate?