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 D
Explanation
Magnesium sulfate is a medication commonly used to treat preeclampsia, a pregnancy-related condition characterized by high blood pressure and damage to other organ systems, such as the kidneys. However, magnesium sulfate can also cause adverse reactions, and the nurse should be aware of these reactions.
The nurse should recognize that a urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate, as magnesium sulfate can cause decreased urine output, which can lead to dehydration and electrolyte imbalances. The nurse should promptly report this finding to the provider, as it may require immediate intervention.
Option A is incorrect because hypertension is a symptom of preeclampsia, not an adverse reaction to magnesium sulfate.
Option B is also incorrect because hyperglycemia is not an adverse reaction to magnesium sulfate.
Option C is also incorrect because a respiratory rate of 16/min is within the normal range.
Correct Answer is ["C","D"]
Explanation
The nurse should plan to immunize the client with the following vaccines: Inactivated influenza: The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women receive the influenza vaccine during any trimester of pregnancy, as pregnant women are at an increased risk of severe illness from the flu.
Diphtheria-acellular pertussis: The CDC recommends that pregnant women receive the Tdap vaccine (which includes protection against tetanus, diphtheria, and acellular pertussis) during each pregnancy, ideally between 27 and 36 weeks of gestation. This is to protect both the mother and the newborn from pertussis (whooping cough).
The following vaccines are not recommended:
Measles, mumps and rubella vaccine should not be given during pregnancy.
The HPV vaccine is not routinely recommended during pregnancy, and if the client becomes pregnant while receiving the HPV vaccine series, vaccination should be delayed until after the pregnancy.
The varicella vaccine (which protects against chickenpox) is not recommended during pregnancy, and if the client is not immune to chickenpox, the vaccine should be given after the pregnancy is over.
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