A nurse is assisting in planning care and is reviewing the electronic medical record for five newborns on a maternal newborn unit.
After evaluation, select the 2 newborns who require revision of the plan of care.
Newborn 4
Newborn 3
Newborn 1
Newborn 2
Newborn 2
Correct Answer : A,C
A. Newborn 4:
This newborn has hypoglycemia (blood glucose 28 mg/dL; normal >40–45 mg/dL) and symptoms such as mild grunting, poor tone, and hand tremors. These findings require immediate intervention to prevent neurologic injury.
B. Newborn 3:
This newborn’s data is within expected limits for a 48-hour-old baby scheduled for discharge. Breastfeeding, voiding, stooling, and passing the hearing screen are appropriate findings; no revision needed.
C. Newborn 1:
Acrocyanosis is normal in the first 24 hours, but this newborn is only 2 hours old, so this alone is not alarming. However, because the newborn had an Apgar score of 6 at 1 minute (indicating some initial difficulty) and is in the early transition period, close monitoring is essential. The revision here would be to ensure additional observation to confirm stability before assuming the newborn is low risk.
D. Newborn 2:
This newborn underwent a circumcision and is being observed per protocol with no abnormal findings; no plan of care revision is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Transcribe the medication name using the trade name:
Nurses should use the generic name to avoid confusion and ensure clarity, not the trade name.
B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day":
This is incorrect; using abbreviations in verbal orders increases risk of misinterpretation-nurses should use clear, plain language like “twice daily.”
C. Remind the provider to countersign the prescription in 72 hr:
Countersigning must occur, but the required time frame varies by facility and jurisdiction-focusing on the time frame is less important than verifying accuracy during the read-back.
D. Verify the medication name along with its intended purpose:
Best practice in telephone orders includes reading back the medication name, dose, route, and frequency, and confirming the indication to reduce medication errors.
Correct Answer is D
Explanation
A. Reposition the client for pain relief:
This is independent nursing care, not interdisciplinary.
B. Develop a client-specific nursing diagnosis:
This is part of the nursing process performed independently by nurses.
C. Change the client's dressing every shift:
This is a nursing intervention, not necessarily interdisciplinary unless specialized input is needed.
D. Collaborate with the respiratory therapist on pulmonary care:
Interdisciplinary care involves collaboration between different healthcare professionals; working with a respiratory therapist is an example.
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