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. At 12 weeks of gestation, the nurse should expect to find the fetal heart tones in the suprapubic area. This is where the uterus is located at this early stage of pregnancy.
B. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The umbilical area is not the typical location for auscultating fetal heart tones at this stage.
C. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. At this stage, the nurse should expect to find fetal heart tones in the suprapubic region.
D. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The liver is typically not involved in auscultating fetal heart tones at this stage.
Correct Answer is D
Explanation
A. Elevating a baby's head on a cushion during sleep is not recommended, as it may increase the risk of Sudden Infant Death Syndrome (SIDS).
B. Using baby powder with each diaper change is not recommended, as it can be harmful if inhaled by the baby.
C. Setting the hot water heater to 130 degrees Fahrenheit is too hot and can scald a baby. The recommended temperature is around 120 degrees Fahrenheit.
D. This statement indicates an understanding of the importance of regularly changing smoke detector batteries, which is a critical aspect of newborn safety.
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