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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Assessing pain intensity with contraction is not the priority when preeclampsia is suspected. The client's headache, hypertension, and edema indicate a need to evaluate for more specific signs of preeclampsia.

Choice B rationale

Fetal heart rate assessment is important, but evaluating maternal status is more urgent when preeclampsia symptoms are present. Monitoring maternal indicators helps determine the severity of preeclampsia.

Choice C rationale

Checking temperature, pulse, and respirations is part of routine assessment, but it does not provide specific information related to preeclampsia. Other assessments are more relevant for the client's condition.

Choice D rationale

Assessing deep tendon reflexes and clonus helps identify severe preeclampsia and potential for eclampsia. Hyperreflexia and clonus are signs of central nervous system irritability, requiring immediate attention and intervention.

Correct Answer is ["36"]

Explanation

Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.

Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.

Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.

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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?

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Naxlex Comprehensive Predictor Exams

A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Correct Answer is D

Explanation

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["36"]

Explanation

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