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.

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Correct Answer is C

Explanation

A. Dilate the pupil so the red reflex can be visualized:
This statement is not accurate regarding the purpose of the eye ointment. The eye ointment is not used to dilate the pupil but serves a different purpose.

B. Prevent herpes infection:
While eye ointment can help prevent certain eye infections, it's not specifically administered to prevent herpes infection.

C. Prevent eye infections:
This is the correct answer. The eye ointment typically contains an antibiotic and is applied to prevent infections, particularly those that could be transmitted during childbirth.

D. Clear the infant's vision:
The eye ointment is not used to clear the infant's vision. Its primary purpose is to prevent infections rather than affect vision.

A. Chromosomal abnormalities B. Sex and size of the infant C. Lecithin-sphingomyelin ratio D. Fetal growth and gestational age.

Correct Answer is D

Explanation

A. Chromosomal abnormalities:

While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.

B. Sex and size of the infant:

An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.

C. Lecithin-sphingomyelin ratio:

The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.

D. Fetal growth and gestational age:

This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.

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Naxlex Comprehensive Predictor Exams

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to

Correct Answer is C

Explanation

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Correct Answer is D

Explanation

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?

A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

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?