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 []

Explanation

Condition: Preeclampsia with severe features.

2 actions:

Administer magnesium sulfate as prescribed,

Monitor for signs of magnesium toxicity.

2 parameters:

Urine output of at least 30 mL/hour,

Deep tendon reflexes.

Rationale for correct condition: Preeclampsia with severe features is indicated by the elevated blood pressure of 170/98 mm Hg and the need for magnesium sulfate. The goal is to prevent eclampsia and manage severe preeclampsia symptoms. The variable decelerations noted in the fetal heart rate are consistent with preeclampsia. The client's blood pressure is critically high, requiring immediate intervention. Magnesium sulfate is used to prevent seizures in severe preeclampsia.

Rationale for actions: Administering magnesium sulfate is essential to prevent seizures associated with severe preeclampsia. It stabilizes the client and reduces the risk of eclampsia. Monitoring for signs of magnesium toxicity ensures safe administration. Symptoms like respiratory depression and loss of reflexes indicate toxicity, requiring dose adjustment. Preparing for an emergency cesarean section is not immediately necessary. Placing the client in a supine position can worsen blood pressure. Restricting fluid intake is not a priority without signs of fluid overload.

Rationale for parameters: Monitoring urine output ensures kidney function and fluid balance. Preeclampsia can affect renal function, making this parameter critical. Deep tendon reflexes help assess neurological status and detect magnesium toxicity early. Changes in reflexes guide dosage adjustments. Fetal heart rate variability is important but secondary here. Oxygen saturation is stable and less relevant. Serum magnesium levels above 8 mg/dL indicate toxicity and are not the target.

Rationale for incorrect conditions: Gestational hypertension involves elevated blood pressure without severe features or the need for magnesium sulfate. Placental abruption would present with more severe pain and bleeding. Preterm labor does not align with the focus on hypertension and magnesium sulfate use.

A. Flexion of all four extremities. B. A positive Babinski reflex. C. Cries vigorously when stimulated. D. Heart rate of 220 beats/minute.

Correct Answer is C

Explanation

Choice A rationale

Flexion of all four extremities is a normal finding in newborns but does not specifically indicate successful transition to extrauterine life. It suggests good muscle tone, which is important, but vigorous crying is a more direct sign of effective respiratory effort and lung function.

Choice B rationale

A positive Babinski reflex is a normal reflexive response in newborns, indicating proper neurological function. However, it does not provide direct information about the newborn's respiratory or cardiovascular adaptation to life outside the womb.

Choice C rationale

Crying vigorously when stimulated is a strong indicator that the newborn is transitioning well to extrauterine life. It demonstrates that the infant's lungs are functioning properly, and they are capable of clearing airway secretions and maintaining adequate oxygenation, which are critical for survival outside the uterus.

Choice D rationale

A heart rate of 220 beats/minute is significantly higher than the normal range for newborns (120-160 beats/minute). Such tachycardia could indicate stress, dehydration, or underlying cardiac issues and does not reflect a normal transition to extrauterine life. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth.Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is C

Explanation

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)

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 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?

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?

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?