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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

A. Apply elastic stockings before the client gets out of bed. B. Apply warm, moist packs to the client's lower legs. C. Have the client ambulate as often as possible. D. Administer NSAIDs every 4 to 6 hours.

Correct Answer is C

Explanation

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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A nurse is receiving change-of-shift report for four newborns. Which of the following newborns should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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