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","C","D","E"]
Explanation
The correct answer is Choice A, Choice C, Choice D, Choice E.
Choice A rationale
Genetic counseling is recommended for couples concerned about birth defects to identify any potential genetic abnormalities or risks for inherited conditions.
Choice B rationale
Couples excited about having children do not necessarily require genetic counseling unless there are known risk factors or concerns about genetic conditions.
Choice C rationale
Loss of an embryo following an in-vitro fertilization procedure may indicate underlying genetic issues, warranting further evaluation through genetic counseling.
Choice D rationale
Huntington’s disease is an autosomal dominant disorder; individuals with a family history should seek genetic counseling to assess their risk of inheritance and possible transmission.
Choice E rationale
In-vitro fertilization with donated sperm may involve genetic screening and counseling to ensure the donor's genetic profile is compatible and free of heritable conditions.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Routine pediatric check-ups typically occur 2–4 weeks after birth. This allows the pediatrician to monitor the baby's growth, development, and overall health, including weight gain and feeding patterns.
Choice B rationale
Home bilirubin lights are recommended for treating neonatal jaundice, a common condition in newborns. Bilirubin lights help lower bilirubin levels in the baby's blood, preventing potential complications like kernicterus.
Choice C rationale
Postpartum obstetrician appointments are usually scheduled 6–8 weeks after delivery to assess the mother's recovery, address any postpartum concerns, and provide guidance on contraception and future pregnancies.
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