A newborn, who is 4 hours old, presents with the following symptoms: 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, hypotonicity, and a weak cry.
What should the nurse do based on these findings?
Swaddle the infant in a warm blanket.
Document the findings in the record.
Place a pulse oximeter on the infant’s heel.
Obtain a heel stick blood glucose level.
The Correct Answer is D
Choice A rationale
While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.
Choice B rationale
Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.
Choice C rationale
Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.
Choice D rationale
Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Correct Answer is A
Explanation
Choice A rationale
A pudendal block is a type of anesthesia that results in a loss of sensation confined to the vagina and perineum. It’s often used during the second stage of labor or for episiotomy repair.
Choice B rationale
A paracervical block provides anesthesia to the cervix and the lower part of the uterus, but it does not specifically target the vagina and perineum.
Choice C rationale
An epidural block provides a band of numbness from the bellybutton to the upper legs, allowing the patient to be awake and alert throughout labor. It’s not confined to the vagina and perineum.
Choice D rationale
A saddle block is a type of spinal anesthesia that numbs the inner thighs, buttocks, and area around the rectum (the “saddle” area), but it’s not confined to the vagina and perineum.
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