Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?

Give blow-by oxygen via cannula.

Start IV infusion in a scalp vein.

Assist neonatologist with intubation.

Provide positive pressure ventilation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

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Correct Answer is A

Explanation

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .

A. These findings are within normal limits and require routine follow-up. B. All findings are outside of the acceptable range and should be reported to the healthcare provider immediately. C. The primary IV fluids should be increased to assist in increasing the urinary output. D. The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Correct Answer is B

Explanation

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?

The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents.The child is anxious, has a temperature of 102.8°F (39.3°C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?