Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
Obtain a heel stick blood glucose level.
Document the findings in the record.
Swaddle the infant in a warm blanket.
Place a pulse oximeter on the heel.
The Correct Answer is A
Choice A rationale
A heel stick blood glucose test is crucial for an infant showing jitteriness, hypotonicity, and weak cry as these symptoms suggest hypoglycemia which requires immediate confirmation and treatment.
Choice B rationale
Documenting findings is essential but does not address the immediate need to rule out and treat hypoglycemia in the symptomatic newborn.
Choice C rationale
Swaddling the infant provides comfort and warmth but does not address potential hypoglycemia, which is the priority in this case.
Choice D rationale
Placing a pulse oximeter monitors oxygenation but does not directly address the underlying cause of jitteriness and hypotonia, which could be hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Erythromycin ointment is administered to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. Newborns are at risk for eye infections, which can lead to blindness if untreated. Erythromycin ointment provides effective prophylaxis.
Choice B rationale
Neomycin ointment is not indicated for prevention of ophthalmia neonatorum caused by Neisseria gonorrhoeae. It is primarily used for treating minor skin infections and not effective against eye infections in newborns.
Choice C rationale
Tetracaine eye drops are used as a local anesthetic for pain relief during minor eye procedures. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.
Choice D rationale
Latanoprost eye drops are used to treat glaucoma by reducing intraocular pressure. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.
Correct Answer is C
Explanation
Choice A rationale
Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.
Choice B rationale
Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.
Choice C rationale
Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.
Choice D rationale
While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.
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