A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?
A newborn who has blue hands and feet with an axillary temperature of 36.6°C (97.9°F)
A newborn who has lost 12% of her birth weight
A newborn who is 24 hr post-circumcision and has yellow exudate
A newborn who has a blood glucose level of 63 mg/dL
The Correct Answer is A
A. The newborn with blue hands and feet (acrocyanosis) along with a normal axillary temperature of 36.6°C (97.9°F) could indicate a need for further assessment. While acrocyanosis can be normal in newborns, it is essential to monitor for any signs of respiratory distress or circulatory issues. Since this newborn is exhibiting a potential sign of compromised circulation, this infant should be attended to first.
B. A newborn who has lost 12% of her birth weight is concerning, as significant weight loss in newborns can indicate feeding problems or other underlying issues. However, this would not take precedence over potential acute issues like those indicated in option A.
C. A newborn who is 24 hours post-circumcision with yellow exudate is expected to have some discharge as part of the healing process. If the exudate is not foul-smelling and there are no signs of infection, this is typically a normal finding.
D. A newborn with a blood glucose level of 63 mg/dL is within the normal range for newborns, as acceptable levels are typically above 40 mg/dL. Therefore, this does not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.
Correct Answer is B
Explanation
A. The shoulder harness should be placed between the breasts and off to the side of the gravid uterus, not directly across it. This helps reduce the risk of injury in the event of a crash.
B. Moving the seat as far away as possible from the steering wheel reduces the risk of injury from the steering wheel or airbag impact while still allowing the client to drive safely.
C. The lap belt should be worn low across the hips and under the abdomen, not high across the abdomen, to protect the growing fetus and prevent harm during sudden deceleration.
D. Airbags should not be disabled as they provide essential protection during a crash. Proper seatbelt use and correct seating position allow airbags to function effectively without posing a risk to the pregnant client.
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