A nurse is assisting with the care of a newborn who is 4 hr old.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

- Potential Condition: Hypoglycemia

- Rationale: The jitteriness and weak cry can be signs of hypoglycemia, which is common in newborns, especially those with higher birth weights or whose mothers have diabetes or, in this case, a history of substance use during pregnancy.

Actions to Take:

1. Reinforce with the parent to feed the newborn: Feeding can help to stabilize the newborn's blood sugar levels.

2. Anticipate a prescription to obtain a capillary blood sample: This will confirm the diagnosis by measuring the newborn's blood glucose levels.

Parameters to Monitor:

1. Temperature: To ensure the newborn maintains a normal body temperature, as hypothermia can be associated with hypoglycemia.

2. Respiratory status: To monitor for any changes that could indicate worsening of the condition or other complications.

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Correct Answer is B

Explanation

A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.

A. The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet. B. The newborn turns their head away from the stimulus when their cheek is touched. C. The newborn's fingers curl around the nurse's finger when placed in the newborn's palm. D. The newborn closes their eyes and keeps them closed when tapped on the forehead.

Correct Answer is C

Explanation

A. This describes the stepping reflex, which involves the newborn's legs moving in a stepping motion when the soles of the feet touch a surface, not just flexing at the knees and hips. It is expected but not the most relevant to the of reflex elicitation as stated.
B. The newborn turns toward the stimulus when their cheek is touched, not away. This is known as the rooting reflex, which helps the newborn find the breast or bottle for feeding.
C. The newborn's fingers curling around the nurse's finger is the grasp reflex, a normal and expected finding in newborns. It indicates normal neurological development and reflex activity.
D. The newborn blinking in response to a tap on the forehead is known as the glabellar reflex, but they do not typically keep their eyes closed. It is not a primary reflex assessed in newborns for neurological health.

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Naxlex Comprehensive Predictor Exams

A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?

Correct Answer is B

Explanation

A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

Correct Answer is C

Explanation

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