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 ["The medical term for the soft spot on a baby's skull is fontanelle (or fontanel)."]
Explanation
The medical term for the soft spot on a baby's skull is fontanelle (or fontanel). Fontanelles are gaps between the bones of the skull that allow for the baby's brain to grow and accommodate rapid brain development during infancy. There are typically two fontanelles in a newborn's skull: the anterior fontanelle (located at the top/front of the head) and the posterior fontanelle (located at the back of the head). These fontanelles are composed of connective tissue and remain open during the early months of life, gradually closing as the baby's skull bones fuse together over time. Healthcare professionals often assess fontanelles during routine physical exams of infants. The fontanelle's size and tension can provide valuable information about the baby's hydration status, intracranial pressure, and neurological development.
Normally, the fontanelles should feel relatively soft and flat, indicating proper hydration and brain development. If the fontanelles are sunken or overly tense, it may suggest dehydration or increased intracranial pressure, which requires further evaluation and management. The proper examination of fontanelles is an essential part of newborn care, and any abnormalities observed during assessment should be promptly reported to the healthcare provider for appropriate evaluation and intervention.
Correct Answer is D
Explanation
Choice A rationale:
Notifying the provider immediately may be an appropriate action in certain urgent situations. However, for a newborn who has not voided for the first time yet, it is not an immediate emergency. The priority is to assess the newborn's condition further before notifying the provider.
Choice B rationale:
Pressing on the bladder to prevent urine retention is not a recommended action. Applying pressure on the newborn's bladder can be harmful and is not a standard nursing practice.
Choice C rationale:
Administering IV fluid is not the priority action for a newborn who has not voided. Newborns usually receive sufficient hydration from breastfeeding or formula feeding, and administering IV fluid without proper indication can lead to potential complications.
Choice D rationale:
Documenting and continuing monitoring is the correct priority action in this situation. Newborns often take some time to pass their first urine, and it is considered normal for them to have delayed voiding within the first 24 hours after birth. The nurse should document the absence of voiding and monitor the newborn for any signs of distress or abnormalities. If the newborn's condition worsens or if there are other concerning symptoms, then notifying the provider may be necessary.
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