A nurse is caring for a newborn who is 4 hours old. The newborn is lying in the bassinet, lightly swaddled.

The newborn appears jittery with a weak cry when disturbed. The extremities are mottled with acrocyanosis.

The respirations are rapid and unlabored. What action should the nurse take?

Monitor the newborn’s vital signs

Swaddle the newborn more tightly

Administer oxygen to the newborn

Notify the healthcare provider .

Answer and Explanation

The Correct Answer is A

Choice A rationale
The newborn’s symptoms, such as being jittery with a weak cry when disturbed, mottled extremities with acrocyanosis, and rapid, unlabored respirations, are signs of neonatal abstinence syndrome. This condition can occur in newborns exposed to certain drugs while in the mother’s womb. The first step in managing this condition is to monitor the newborn’s vital

signs. This will help the healthcare team assess the newborn’s condition and determine the appropriate treatment plan. Monitoring vital signs is a crucial part of nursing care, especially for newborns who are showing signs of distress. It provides valuable information about the newborn’s physiological status and response to the environment. Regular monitoring can help detect any changes in the newborn’s condition early, allowing for timely intervention.
Choice B rationale
Swaddling the newborn more tightly is not the best action to take in this situation. While swaddling can provide comfort and help soothe a fussy baby, it is not a treatment for the symptoms the newborn is exhibiting. Furthermore, swaddling should be done correctly to avoid any potential risks such as overheating or hip dysplasia. In this case, the newborn’s symptoms need to be addressed directly, which is why monitoring vital signs is a more appropriate action.
Choice C rationale
Administering oxygen to the newborn is not the most appropriate action based on the symptoms described. While the newborn’s respirations are rapid, they are also unlabored, which suggests that the newborn is not currently experiencing respiratory distress. Oxygen therapy is typically reserved for situations where the newborn is showing signs of respiratory distress, such as grunting, flaring nostrils, or cyanosis around the mouth and tongue. In this case, the acrocyanosis (bluish color of hands and feet) is a common and normal finding in newborns due to immature circulation and is not an indication for oxygen therapy.
Choice D rationale
Notifying the healthcare provider is an important step when caring for a newborn showing signs of distress. However, in this situation, the first action the nurse should take is to monitor

the newborn’s vital signs. This will provide valuable information about the newborn’s current condition that can be reported to the healthcare provider. It’s important for the nurse to gather as much information as possible before contacting the healthcare provider so that they can have a productive discussion about the newborn’s condition and the next steps in their care.

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Correct Answer is A

Explanation

Choice A rationale
Asking if the client’s back labor has improved is a good way to evaluate the effectiveness of the hands-and-knees position. This position has been shown to reduce persistent back pain in laboring women with a fetus in the occipitoposterior position.
Choice B rationale

Feeling relief from pelvic pressure is not specifically associated with the hands-and-knees position.
Choice C rationale
Lessening of suprapubic pain is not specifically associated with the hands-and-knees position.
Choice D rationale
Contractions feeling further apart is not a specific outcome associated with the hands-and- knees position.

A. You didn’t report any symptoms of GBS during your pregnancy. B. Your previous deliveries were all negative for GBS. C. There was no indication of GBS in your earlier prenatal testing. D. We need to know if you are positive for GBS at the time of delivery.

Correct Answer is D

Explanation

Choice A rationale

While it’s true that symptoms of GBS in pregnant women are often not apparent, the absence of symptoms does not eliminate the risk of transmission to the baby during delivery.
Therefore, this is not the primary reason for the timing of the test.
Choice B rationale
Even though a woman’s previous deliveries were negative for GBS, it doesn’t mean she won’t have GBS in subsequent pregnancies. GBS can come and go in a person’s body without symptoms, so even if previous tests were negative, a woman could still have GBS in her current pregnancy.
Choice C rationale
GBS is not typically part of early prenatal testing. It is usually tested for late in the third trimester because a woman can test negative earlier in pregnancy and be positive by the time of delivery.
Choice D rationale
This is the correct answer. The primary reason for testing for GBS late in pregnancy is to identify women who are GBS positive at the time of delivery, as these women have a risk of transmitting GBS to their newborns during delivery.

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A nurse is caring for a newborn who is 4 hours old. The newborn is lying in the bassinet, lightly swaddled. The newborn appears jittery with a weak cry when disturbed. The extremities are mottled with acrocyanosis. The respirations are rapid and unlabored. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position.Which of the following Questions should the nurse ask to evaluate the effectiveness of this intervention?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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A nurse is caring for a newborn who is 4 hours old. The newborn is lying in the bassinet, lightly swaddled.

The newborn appears jittery with a weak cry when disturbed. The extremities are mottled with acrocyanosis.

The respirations are rapid and unlabored. What action should the nurse take?