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
Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.
Choice B rationale
Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.
Choice C rationale
The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.
Choice D rationale
Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.
Correct Answer is ["B","D","F","G"]
Explanation
Choice B rationale
Proteinuria indicates preeclampsia, which involves increased glomerular permeability due to endothelial damage. Normal protein in urine is <150 mg/day.
Choice F rationale
Hyperreflexia can be a sign of CNS irritability in preeclampsia, which can lead to seizures if untreated. Normal reflexes are 2+.
Choice G rationale
Assessing lung sounds is critical as pulmonary edema can develop in severe preeclampsia due to increased capillary permeability. Normal breath sounds are clear and equal bilaterally.
Choice D rationale
A vision test helps assess for visual disturbances due to cerebral edema or optic nerve involvement in preeclampsia. Normal visual acuity is 20/20.
Choice A rationale
Hemoglobin assessment could indicate anemia, but it does not specifically address preeclampsia symptoms. Normal hemoglobin is 12-16 g/dL for women.
Choice C rationale
Perineal assessment checks for infection or hematoma but is less likely to explain systemic symptoms like headache and dizziness.
Choice E rationale
Skin turgor assesses hydration status, but dehydration is less likely to explain severe headache, dizziness, and visual disturbances. Normal skin turgor is immediate recoil.
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