A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?
A newborn who is 8 hr old and has acrocyanosis.
A newborn who is 18 hr old and has not voided.
A newborn who is 24 hr old and has not passed meconium.
A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).
The Correct Answer is D
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not report the client's Hemoglobin level first to the primary health care because it falls within the normal range of 14 to 24 g/dL for a newborn. Therefore, it is not an immediate concern.
Choice B rationale:
The nurse should first report the client's Chest x-ray results to the primary health care. The diffuse pattern of radiopaque areas bilaterally on the chest x-ray suggests possible respiratory distress or other respiratory issues in the newborn. This finding requires immediate attention and intervention to ensure proper respiratory function.
Choice C rationale:
The nurse should not report the client's Glucose level first to the primary health care as 40 mg/dL is within the normal range of 30 to 60 mg/dL for a newborn. Though it is on the lower side, it is not critically low, and there are more urgent concerns to address.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.
Choice B rationale:
Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.
Choice C rationale:
Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.
Choice D rationale:
Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.
Choice E rationale:
Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.
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