Assessment findings of a 4-hour-old newborn include an axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and a weak cry.
Based on these findings, which action should the nurse implement?

Obtain a heel stick blood glucose level.

Swaddle the infant in a warm blanket.

Place a pulse oximeter on the heel.

Document the findings in the record.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The symptoms of jitteriness, hypotonia, weak cry, and low temperature can indicate hypoglycemia in a newborn. Obtaining a heel stick blood glucose level is crucial to confirm the diagnosis and provide appropriate treatment.

Choice B rationale

While keeping the infant warm is important, it does not address the underlying issue of potential hypoglycemia, which needs to be identified and treated promptly.

Choice C rationale

Placing a pulse oximeter on the heel assesses oxygen saturation, which is not directly related to the symptoms described. The primary concern here is glucose level, not oxygen saturation.

Choice D rationale

Documenting the findings is important but does not provide immediate intervention for potential hypoglycemia, which requires urgent glucose level assessment and treatment if necessary. .

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Correct Answer is D

Explanation

Choice A rationale

Genital warts, caused by human papillomavirus (HPV), typically present as small, flesh-colored or gray swellings in the genital area. They do not usually cause pain or vesicular lesions like those described. Genital warts may be flat or cauliflower-like in appearance but are generally distinct from the symptoms described in the question.

Choice B rationale

German measles (rubella) is a viral infection characterized by a red rash, mild fever, and swollen lymph nodes. It is not associated with vesicular lesions on the genital area. The virus primarily affects the respiratory system, and symptoms do not typically include shallow vesicles on the pubis, labia, and perineum.

Choice C rationale

Syphilis, caused by the bacterium Treponema pallidum, presents in stages. Primary syphilis manifests as a single sore (chancre), while secondary syphilis involves skin rashes and mucous membrane lesions. Tertiary syphilis can cause severe medical problems. The symptoms described do not align with any syphilis stage but rather suggest a different condition.

Choice D rationale

Herpes simplex virus (HSV) causes painful, shallow vesicles or ulcers in the genital area. HSV lesions are typically small, fluid-filled blisters that can rupture and form ulcers. The client's symptoms of shallow, small vesicles on her pubis, labia, and perineum are indicative of genital herpes.

A. Yogurt. B. Collard greens. C. Whole milk. D. Strawberries.

Correct Answer is D

Explanation

Choice A rationale

Yogurt is a good source of calcium and protein but is not particularly high in folic acid. It is beneficial for overall health but not the best option for increasing folic acid intake.

Choice B rationale

Collard greens are high in folic acid, but since the client does not like green leafy vegetables, this option is not suitable for her.

Choice C rationale

Whole milk provides vitamin D and calcium, but it is not a significant source of folic acid. It would not effectively help the client meet her increased folic acid needs.

Choice D rationale

Strawberries are a good source of folic acid and can be a suitable option for the client to increase her intake without consuming green leafy vegetables or soy products. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

Correct Answer is D

Explanation

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid.The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

Correct Answer is D

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

A client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive.Which action(s) should the nurse plan to perform? Select all that apply.

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.Which action should the nurse implement first?

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?