A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.
Which assessment action should the nurse prioritize?
Conduct a gestational age assessment.
Weigh and measure the newborn.
Evaluate the neonatal reflexes’ reactivity.
Perform a drug screen for cocaine.
The Correct Answer is D
Choice A rationale
While conducting a gestational age assessment is important, it is not the priority in this situation.
Choice B rationale
Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.
Choice C rationale
Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.
Choice D rationale
Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.
Choice B rationale
Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.
Choice C rationale
Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.
Choice D rationale
Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.
Correct Answer is A
Explanation
Choice A rationale
A pudendal block is a type of anesthesia that results in a loss of sensation confined to the vagina and perineum. It’s often used during the second stage of labor or for episiotomy repair.
Choice B rationale
A paracervical block provides anesthesia to the cervix and the lower part of the uterus, but it does not specifically target the vagina and perineum.
Choice C rationale
An epidural block provides a band of numbness from the bellybutton to the upper legs, allowing the patient to be awake and alert throughout labor. It’s not confined to the vagina and perineum.
Choice D rationale
A saddle block is a type of spinal anesthesia that numbs the inner thighs, buttocks, and area around the rectum (the “saddle” area), but it’s not confined to the vagina and perineum.
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