A nurse in a newborn nursery is receiving change-of-shift report for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who is 24 hr old and has not had a meconium stool.
A newborn who has a short frenulum and is having difficulty breastfeeding.
A newborn who is 10 hr old and has onset tachypnea.
A newborn who is 30 hr old and has blood-tinged discharge in her diaper.
The Correct Answer is C
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Thrombocytopenia is defined as a platelet count of less than 150,000/microL1.
Severe neonatal thrombocytopenia (platelet count <50,000/microL) can be associated with bleeding and potentially significant morbidity.
As a result, it is important to identify at-risk neonates and report low platelet counts to the provider.
Choice B is incorrect because a hematocrit of 48% is within the normal range for a newborn.
Choice C is incorrect because a blood glucose level of 58 mg/dl is within the normal range for a newborn.
Choice D is incorrect because a hemoglobin level of 16 g/dL is within the normal range for a newborn.
Correct Answer is A
Explanation
“I will drink water before the test until my bladder feels full.” Drinking water before an abdominal ultrasound is usually recommended to ensure a full bladder.
Choice B is incorrect because fasting for 8-12 hours before an abdominal ultrasound is usually recommended.
Choice C is incorrect because there is no information found that suggests avoiding perfumed lotion on the abdomen before an abdominal ultrasound.
Choice D is incorrect because there is no information found that suggests taking a stool softener before an abdominal ultrasound.
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