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. Applying a warm pack to the puncture site before the procedure increases blood flow to the area, which makes the blood sample collection easier and reduces discomfort for the newborn.
B. A mummy restraint may not be necessary for a routine blood glucose test. The nurse can gently hold the newborn in place during the procedure without needing to fully restrain them.
C. Antiseptic solution is typically applied before the puncture to cleanse the area. After the procedure, gentle pressure and bandaging are more appropriate to stop bleeding.
D. Elevating the extremity is unnecessary for a newborn blood glucose test, as warming the area is more effective in promoting blood flow to the puncture site.
Correct Answer is D
Explanation
A. a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B. erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C. acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D. an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.
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