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. Determine fetal position by performing Leopold maneuvers. B. Assess the fetal heart rate and client's contraction pattern C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration D. Perform sterile vaginal examination to determine dilatation

Correct Answer is B

Explanation

A. Determine fetal position by performing Leopold maneuvers:
Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.

B. Assess the fetal heart rate and client's contraction pattern:
This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.

C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration:
While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.

D. Perform sterile vaginal examination to determine dilatation:
Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.

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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

Correct Answer is B

Explanation

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