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 A
Explanation
"My baby will be placed under special lights if the test is elevated.”.
Choice A rationale:
This statement indicates a need for further teaching. Phenylketonuria (PKU) is a metabolic disorder that leads to the accumulation of phenylalanine in the body. If the PKU test is elevated, it means that the baby has high levels of phenylalanine, and immediate dietary intervention is required. The parent's statement about special lights suggests a confusion with jaundice treatment, which is not related to PKU.
Choice B rationale:
This statement is accurate. Before the PKU test is done, the baby needs to consume formula or breast milk to ensure accurate test results.
Choice C rationale:
This statement is also accurate. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine. By adhering to the prescribed diet, the harmful effects of PKU can be minimized.
Choice D rationale:
This statement is accurate. It is common for the PKU test to be repeated at the 2-week check- up to confirm the initial results and ensure early detection and management of PKU if present.
Correct Answer is C
Explanation
Choice A rationale:
A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.
Choice B rationale:
A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.
Choice C rationale:
A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.
Choice D rationale:
A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.
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