A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation.

A newborn who is 38 weeks of gestation is admitted to the newborn nursery following an emergency cesarean birth with respiratory distress syndrome (RDS). Apgar scores of 5 at 1 min and 7 at 5 min. The newborn received surfactant via an endotracheal tube and is currently receiving 3 Umin of oxygen via nasal cannula. Blood gases reveal respiratory acidosis.

Which action should the nurse prioritize in this situation?

Report the client's weight by the client's provider.

Select diagnostic studies followed by the primary health care.

Check brachial pulses for the client's respiratory status.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.

Choice B rationale:

Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.

Choice C rationale:

Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Iron is crucial for the development of hemoglobin, which carries oxygen to all parts of the body, including the bones, but it does not directly facilitate bone growth.

Choice B rationale:

While newborns do metabolize iron, their iron stores are limited, and breast milk alone may not meet their iron needs.

Choice C rationale:

When educating a parent about the use of iron-fortified formula for their newborn, it is essential to convey that newborns have a limited store of iron, which begins to deplete around the age of 6 months.

Choice D rationale:

Iron facilitating eyesight development is not a relevant aspect to consider when discussing the use of iron-fortified formula for a newborn. While iron is essential for various physiological functions, it is not specifically linked to eyesight development.

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old. B. A hematocrit of 60% in an infant who is 8-hr old. C. Jaundice in an infant who is 4-hr old. D. Acrocyanosis in an infant who is 2-hr old.

Correct Answer is C

Explanation

A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.

B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion

C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.

D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a parent about using an iron-fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Correct Answer is C

Explanation

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

A mother who is holding her 2-hour-old newborn says, "I don't think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.”. Which is the nurse's best response?

A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation. Exhibits Which action should the nurse take first?