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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Gravidity refers to the total number of times a woman has been pregnant, regardless of the outcome. This client has had one full-term infant, one premature infant, and one miscarriage, plus the current pregnancy, making a total of four pregnancies.
Choice B rationale
Gravidity is not determined by the number of live births. This client has had more than three pregnancies, so Gravida 3 is incorrect.
Choice C rationale
Gravidity does not count the number of live births and miscarriages separately. It counts the total number of pregnancies, making Gravida 5 incorrect in this context.
Choice D rationale
Gravida 2 would only apply if the client had been pregnant twice, which is not the case here.
Correct Answer is A
Explanation
Choice A rationale
Misoprostol is a synthetic prostaglandin E1 (PGE1) analog that can induce uterine contractions, increasing the risk of a spontaneous miscarriage, particularly in early pregnancy.
Choice B rationale
Misoprostol is not known to increase the risk of preeclampsia. Preeclampsia involves high blood pressure and potential damage to other organ systems, typically appearing after 20 weeks of pregnancy.
Choice C rationale
Misoprostol does have an effect on the unborn child due to its ability to cause uterine contractions and cervical ripening, potentially leading to miscarriage.
Choice D rationale
Misoprostol is not associated with an increased risk of postpartum hemorrhaging after delivery. It is often used to manage postpartum hemorrhage by promoting uterine contractions.
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