A nurse is caring for a newborn.

The newborn was delivered via cesarean birth approximately 1 hr ago.

The Apgar Scores are 8 and 9. Vitamin K was administered in the left vastus lateralis.

The weight is 4337 grams (9 lb 9 oz), length 52 cm (20.5 in), and gestational age assessment of 39 weeks. The newborn is large for gestational age and noted to be jittery and have decreased muscle tone. Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn’s progress.

Check the newborn’s capillary blood glucose level.

Place the newborn under a radiant warmer.

Monitor the newborn’s temperature.

Monitor the newborn’s color and frequency of bowel movements.

Answer and Explanation

The Correct Answer is A,B,C

Choice A rationale

Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.

Choice B rationale

Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.

Choice C rationale

Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.

Choice D rationale

Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.

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Correct Answer is B

Explanation

Choice A rationale

Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.

Choice B rationale

Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.

Choice C rationale

Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.

Choice D rationale

Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.

A. The newborn is at risk for developing neonatal abstinence syndrome as evidenced by the urine toxicology screen results. B. The newborn is at risk for developing neonatal jaundice as evidenced by the yellowish skin tone. C. The newborn is at risk for developing neonatal hypoglycemia as evidenced by the low birth weight. D. The newborn is at risk for developing neonatal sepsis as evidenced by the maternal history of infection. E. The newborn is at risk for developing neonatal sepsis as evidenced by the maternal history of infection.

Correct Answer is C

Explanation

Choice A rationale

Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.

Choice B rationale

While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.

Choice C rationale

Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.

Choice D rationale

Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered a newborn. The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a newborn who is 4 hours old. After reviewing the information in the newborn’s medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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