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 D
Explanation
Choice A rationale
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
Choice B rationale
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
Choice C rationale
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
Choice D rationale
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
Correct Answer is A
Explanation
Choice A rationale
In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.
Choice B rationale
While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.
Choice C rationale
Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.
Choice D rationale
Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.
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