A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

Blue coloring of the hands and feet in an 8-hour-old newborn.

Small raised pearly spots on the newborn's nose.

Apical heart rate of 140 bpm.

Nasal flaring and grunting.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.

Choice B rationale

Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.

Choice C rationale

An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.

Choice D rationale

Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.

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Correct Answer is B

Explanation

Choice A rationale

Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.

Choice B rationale

Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.

Choice C rationale

Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.

Choice D rationale

Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.

A. Elevated WBC count. B. Elevated platelet count. C. Decreased BUN. D. Elevated liver enzymes.

Correct Answer is D

Explanation

Choice A rationale

Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.

Choice B rationale

Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.

Choice C rationale

Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.

Choice D rationale

Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .

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A nurse is caring for four newborns in a special care nursery.Which of the following newborn assessment findings requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?