A nurse receives handoff report. Which newborn should the nurse assess first?
Glucose reading 58 mg/dL.
Pulse 144 beats/minute.
Respiratory rate 78 breaths/minute.
Temperature 97.7° F (36.5° C).
The Correct Answer is C
Choice A reason:
While hypoglycemia (glucose <45 mg/dL) is concerning, 58 mg/dL is within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Newborns typically have a normal respiratory rate of 30-60 breaths/minute. A rate of 78 indicates significant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
The cord is still pulsating. This is not the first thing a nurse must ensure when the head comes out because the cord normally pulsates until the placenta is delivered. The pulsation indicates that the cord is still functioning and transferring blood and oxygen between the baby and the placenta. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord (a cord wrapped around the neck) or a prolapsed cord (a cord that slips out before the baby). • Choice B reason:
The cord is intact. This is not the first thing a nurse must ensure when the head comes out because the cord is usually intact until it is clamped and cut after the delivery of the baby. The cord can be ruptured by excessive traction or twisting, which can cause bleeding and shock in the baby. However, this is a rare occurrence and does not pose an immediate threat to the baby's life as long as the cord is still attached to the placenta. • Choice C reason:
No part of the cord is encircling the baby's neck. This is the correct answer because a nuchal cord can cause compression of the cord and reduce blood flow and oxygen to the baby, leading to fetal distress, hypoxia, and brain damage. A nuchal cord occurs in about 10 to 30 percent of deliveries and can be detected by feeling for a loop of cord around the neck as the head emerges. If a nuchal cord is present, it should be gently slipped over the head or clamped and cut before delivery of the shoulders. • Choice D reason:
The cord is still attached to the placenta. This is not the first thing a nurse must ensure when the head comes out because the cord is always attached to the placenta until it separates from the uterine wall and is expelled after the delivery of the baby. The placenta provides nourishment and oxygen to the baby through the cord. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord or a prolapsed cord.
Correct Answer is D
Explanation
Choice A reason:
The woman in early labor with contractions every 5 minutes lasting 40 seconds each does not require the immediate discontinuation of the oxytocin (Pitocin) infusion. Early labor is characterized by mild and infrequent contractions as the cervix begins to dilate and efface. Choice B reason:
The woman in active labor with contractions every 30 minutes lasting 60 seconds each also does not warrant immediate discontinuation of the oxytocin (Pitocin) infusion. Active labor typically involves regular and stronger contractions as the cervix continues to dilate and the baby progresses downward.
Choice C reason:
The woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each does not require immediate cessation of the oxytocin (Pitocin) infusion. These contractions are within the expected range for active labor and may be considered normal.
Choice D reason:
The woman in transition with contractions every 1.5 minutes lasting 95 seconds each should have the oxytocin (Pitocin) infusion discontinued immediately. Transition is the most intense phase of labor, characterized by rapid and strong contractions as the cervix completes dilation. Prolonged and frequent contractions during this phase can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. Discontinuing the oxytocin infusion is necessary to reduce the intensity and frequency of contractions, ensuring better fetal well-being during this critical phase of labor.
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