A nurse receives a handoff report.
Which newborn should the nurse assess first?
Glucose reading 58 mg/dl.
Temperature 97.4°F (36.3°C).
Respiratory rate 48 breaths/minute.
Pulse 134 beats/minute.
The Correct Answer is B
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While it requires attention and intervention to prevent hypoglycemia, it is not as immediately life-threatening as a significantly low temperature.
Choice B rationale
A temperature of 97.4°F (36.3°C) in a newborn is below the normal range (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increased oxygen consumption, and hypoglycemia. This newborn needs immediate assessment and warming measures to prevent complications.
Choice C rationale
A respiratory rate of 48 breaths per minute is within the normal range for a newborn (typically 30-60 breaths per minute). While the nurse will continue to monitor the respiratory status, this finding does not indicate immediate distress.
Choice D rationale
A pulse rate of 134 beats per minute is within the normal range for a newborn (typically 110-160 beats per minute). While the nurse will continue to monitor the cardiovascular status, this finding does not indicate immediate distress. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The stepping reflex, also known as the walking or dancing reflex, is elicited by holding the infant upright with their feet touching a flat surface. The infant will make stepping or dancing movements. This is not elicited by stroking the lateral sole of the foot.
Choice B rationale
The Babinski reflex is elicited by stroking the lateral sole of the infant's foot from the heel upward and across the ball of the foot. A positive Babinski sign is characterized by dorsiflexion of the great toe and fanning out of the other toes. This reflex is normal in infants and typically disappears by 12 to 24 months of age.
Choice C rationale
The tonic neck reflex, also known as the fencing reflex, is elicited by turning the infant's head to one side. The arm and leg on the turned side extend, while the arm and leg on the opposite side flex. Stroking the sole of the foot does not elicit this reflex.
Choice D rationale
The plantar grasp reflex is elicited by placing a finger or object across the base of the infant's toes. The toes will curl downward and grasp the object. This reflex is different from the response elicited by stroking the lateral sole of the foot. .
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B,C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}
Explanation
- Postpartum Endometritis is the most likely concern here, considering the fever, foul-smelling lochia, uterine tenderness, and tachycardia.
- Postpartum Hemorrhage is a possibility due to the boggy uterus and tachycardia, though her bleeding appears moderate.
- Lactational Mastitis is unlikely since the patient has no breast tenderness or redness.
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