A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?
Place the newborn in a radiant warmer.
Initiate phototherapy.
Obtain blood glucose by heel stick.
Measure the newborn's blood pressure.
The Correct Answer is C
Choice A rationale:
Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.
Choice B rationale:
Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.
Choice C rationale:
The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.
Choice D rationale:
Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should first report the client's respiratory status to the primary health care.
Choice A rationale:
Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.
Choice B rationale:
Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.
Choice C rationale:
Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.