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. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

A. Explain that heartburn is a common discomfort. B. Ask if blurred vision and headache have occurred. C. Check urine for presence of glucose and ketones. D. Instruct the client to take an antacid as needed.

Correct Answer is B

Explanation

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

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?

The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?