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 A

Explanation

Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.

Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.

Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.

Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.

A. Hemoglobin A1C. B. Postprandial blood glucose test C. Fasting blood glucose D. Oral glucose tolerance test

Correct Answer is C

Explanation

A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.

B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.

C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.

D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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 new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

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