A nurse in a newborn nursery is organizing a plan of care for four newborns after receiving a change-of-shift report. Which of the following assessments should the nurse perform first?

Check the blood glucose level of a newborn who is 4 hr old and jittery.

Conduct a universal newborn screening on a newborn who is 26 hr old.

Conduct a New Ballard Score for a newborn who is 12 hr old.

Check the temperature of a newborn who is 2 hr old prior to the first bath.

Answer and Explanation

The Correct Answer is A

A. A jittery newborn at 4 hours old may be experiencing hypoglycemia, which is a potentially serious condition requiring immediate assessment and intervention.
B. Universal newborn screening is important but can be delayed until the newborn is more stable.
C. The New Ballard Score is an assessment of gestational age and can be done after stabilization.
D. Checking temperature prior to the first bath is important but less urgent than evaluating possible hypoglycemia.

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Correct Answer is D

Explanation

A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

A. Soft abdomen B. Heart rate 120/min C. A fetal heart of 150/min with moderate variability D. Painless vaginal bleeding

Correct Answer is B

Explanation

A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.

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A nurse in a newborn nursery is organizing a plan of care for four newborns after receiving a change-of-shift report. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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