A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
A newborn who has a short frenulum and is having difficulty breastfeeding
A newborn who is 24 hr old and has not had a meconium stool
A newborn who is 30 hr old and has blood-tinged discharge in her diaper
A newborn who is 10 hr old and has new onset tachypnea
The Correct Answer is D
The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.
A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.
A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The purpose of bathing the newborn before initiating skin-to-skin contact is to decrease the risk of transmission of the virus from the mother to the newborn. Instructing the client to stop taking the antiretroviral medications at 32 weeks of gestation is incorrect as these medications should be taken throughout pregnancy to decrease the risk of transmission to the fetus.
Using a fetalscalp electrode during labor and delivery is also not an appropriate action as it increases the risk of transmission of the virus to the newborn. Administering a pneumococcal immunization to the newborn within 4 hours following birth is not specific to HIV positive newborns and is not related to preventing transmission of the virus.
Correct Answer is A
Explanation
Epidural anesthesia can cause hypotension in the mother, which can decrease blood flow to the fetus. Turning the client onto their side can help to improve blood flow to the fetus by reducing the pressure of the uterus on the vena cava and increasing venous return to the heart.
Option B is incorrect because an amnio-infusion is not indicated for hypotension related to epidural anesthesia.
Option C is also incorrect because naloxone is a medication used to reverse the effects of opioid medications and would not be appropriate for treating hypotension related to epidural anesthesia.
Option D is partially correct but does not address the immediate need to improve blood flow to the fetus. The nurse should monitor the client's blood pressure regularly but should also take immediate action to turn the client onto their side to improve blood flow.
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