Assessment findings of a 4-hour-old newborn include: 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, hypotonic and weak cry. Based on these findings, which action should the nurse implement?

Document the findings in the record

Obtain a heel stick blood glucose level.

Place a pulse oximeter on the heel.

Swaddle the infant in a warm blanket

Answer and Explanation

The Correct Answer is B

A. Document the findings in the record: Documenting the findings is important, but it doesn't address the potential issue of hypoglycemia.

B. Obtain a heel stick blood glucose level: This is the most appropriate action given the signs presented. A low blood glucose level can be a critical issue in newborns and requires prompt evaluation and management.

C. Place a pulse oximeter on the heel: While oxygen saturation monitoring is valuable in certain situations, it may not be the priority in this case where hypoglycemia is suspected.

D. Swaddle the infant in a warm blanket: While maintaining warmth is important, especially if the baby is hypothermic, addressing the potential hypoglycemia takes precedence.

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 A

Explanation

A. Obtain blood and urine for prenatal screens.
This choice is important because it allows the nurse to assess the client's overall health, screen for infections, and identify any potential risks or complications that may impact the pregnancy.

B. Explain common complications of pregnancy.
While educating the client about common complications is valuable, it may not address the immediate need to screen for specific infections or assess the client's current health status. This information can be covered during prenatal education sessions.

C. Obtain baseline blood pressure and weight.
This is a routine part of prenatal care and is important for monitoring the client's health throughout pregnancy. However, if the client has a history of syphilis, obtaining specific prenatal screens (including for syphilis) would be a more targeted and immediate action.

D. Schedule prenatal visits to occur monthly.
Scheduling regular prenatal visits is essential for monitoring the progression of the pregnancy. However, addressing the specific health concerns and obtaining necessary screens take precedence during the initial visit, especially considering the client's history of syphilis.

A. Describe genetic testing protocols B. Discontinue the methadone right away C. Sign up for group therapy sessions D. Start a prenatal care plan as soon as possible

Correct Answer is D

Explanation

A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.

B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.

C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.

D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.

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

The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Correct Answer is D

Explanation

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?