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

Answer and Explanation

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.

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Correct Answer is C, D, A, B

Explanation

C. Ask the client to lie on her back and with her knees flexed.

D. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

A. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

B. Observe the client's perineum for the passage of clots and the amount of bleeding.

A. Monitor the rectal temperature every 4 hr. B. Administer broad-spectrum antibiotics. C. Cleanse the site with povidone-iodine. D. Prepare for surgical closure after 72hr.

Correct Answer is C

Explanation

The priority action in this scenario is to prevent infection. Cleansing the site with povidone-iodine can help reduce the risk of infection. Rectal temperature monitoring and administration of antibiotics may be necessary if infection is suspected, but preventing infection is the priority. Surgical closure may be necessary, but this is not an immediate concern.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C, D, A, B

Explanation

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Explanation

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