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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"He is just cold”. is not the correct choice. While newborns can have cold hands and feet due to their immature thermoregulation, it would not explain persistent blue hands.
Choice B rationale:
"He may have been born with a heart problem”. is not the correct choice as it suggests a congenital heart defect. While cyanosis (bluish discoloration) can be associated with some heart problems, the hands alone being blue is less likely to be solely related to a heart issue.
Choice C rationale:
"The hands are always blue in a newborn”. is not the correct choice. While newborns may have bluish extremities (acrocyanosis) during the first few days after birth due to their developing circulatory system, persistent blue hands beyond this period would require further assessment.
Choice D rationale:
The correct choice is that "The circulation in his hands is not fully developed.”. Newborns have a developing circulatory system, and sometimes, their peripheral circulation takes some time to mature, leading to transient blue hands. However, if the blue color persists or worsens, it's essential to evaluate for any underlying issues.
Correct Answer is B
Explanation
A. Maintaining ambient room temperature at 24° C (75° F) can help prevent heat loss by keeping the environment warm, but it does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, which is not directly controlled by ambient temperature.
B. Drying the newborn's skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This action is critical immediately after birth when the newborn is wet with amniotic fluid.
C. Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air moves across the skin and carries heat away.
D. Placing the newborn on a warm surface helps reduce conductive heat loss by preventing heat transfer from the baby to a cooler surface. However, this does not address evaporative heat loss, which is specifically related to moisture evaporation from the skin.
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