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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.
Choice B rationale
Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.
Choice C rationale
Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately
measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.
Choice D rationale
Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.
Correct Answer is C
Explanation
Choice A rationale
While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.
Choice B rationale
A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.
Choice C rationale
Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.
Choice D rationale
Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.
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