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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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

In the context of a fetus weighing an estimated 8 pounds at 36-weeks gestation in a client with gestational diabetes, an amniocentesis would most likely be performed to assess the maturity of the fetal lungs. This is because babies of mothers with gestational diabetes are at risk for

respiratory distress syndrome if delivered early, and the baby’s size may indicate that early delivery could be beneficial.

Choice B rationale

While amniocentesis can be used to detect neural tube defects, these are usually diagnosed earlier in pregnancy. Furthermore, there is no specific link between gestational diabetes, fetal weight, and neural tube defects that would make this the primary reason for performing an amniocentesis in this scenario.

Choice C rationale

Amniocentesis can be used to detect chromosomal abnormalities. However, these are typically screened for earlier in pregnancy and would not be directly related to the mother’s gestational diabetes or the estimated fetal weight.

Choice D rationale

The gender of the fetus can be determined through amniocentesis, but it can also be determined more simply through ultrasound. Therefore, it is unlikely that an amniocentesis would be performed for this purpose, especially considering the mother’s gestational diabetes and the baby’s size.

A. Clear the infant’s vision. B. Dilate the pupil so the red reflex can be visualized. C. Prevent herpes infection. D. Prevent eye infections.

Correct Answer is D

Explanation

Choice A rationale

The eye ointment used in newborns is not intended to clear the infant’s vision.

Choice B rationale

The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.

Choice C rationale

While the ointment does help prevent infections, it is not specifically targeted against herpes.

Choice D rationale

The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with gestational diabetes is scheduled for an amniocentesis due to the fetus weighing an estimated 8 pounds (3629 grams) at 36-weeks gestation.What information is being sought through this amniocentesis?

Correct Answer is A

Explanation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what is the purpose of the ointment.The nurse would be correct in stating that the purpose for using the ointment is to:

Correct Answer is D

Explanation

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The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

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?