The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority?
Select one:

Obtain a bilirubin level.

Place a pulse oximeter on the newborn.

Obtain a blood glucose level.

Take the newborn's vital signs.

Answer and Explanation

The Correct Answer is C

Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.

Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.

Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and eﬀectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.

Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.

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Correct Answer is D

Explanation

Choice A Reason: About 1 of every 5 women will experience abuse in her lifetime is a statistic that shows the prevalence of domestic violence, but it does not address the question of what the nurse should emphasize to the group of women.

Choice B Reason: When women go back to the situation after the abuser has calmed down, things will be beter is a false statement that reﬂects the cycle of abuse, where the abuser may apologize and promise to change after a violent episode, but then repeat the same behavior later. This does not help the women understand their situation or seek help.

Choice C Reason: The victimized woman can easily leave the situation is a false statement that ignores the many barriers and challenges that women face when trying to escape from domestic violence, such as fear, isolation, financial dependence, lack of support, legal issues, and threats from the abuser. This does not empower the women or provide them with realistic options.

Choice D Reason: The violence will not stop or decrease if the woman becomes pregnant is a true statement that highlights the danger of staying in an abusive relationship during pregnancy. Domestic violence can increase the risk of miscarriage, preterm birth, low birth weight, placental abruption, fetal injury, and maternal death. This may motivate the women to seek safety and protection for themselves and their unborn children.

A. Moderate amounts of deep red lochia. B. Sweating while afebrile. C. Voiding 350 mL of blood-tinged urine. D. Heart rate of 115 beats/minute.

Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

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The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority? Select one:

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Naxlex Comprehensive Predictor Exams

The nurse at a shelter is counseling a group of women experiencing domestic violence. What is most important for the nurse to emphasize? Select one:

Correct Answer is D

Explanation

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Correct Answer is D

Explanation

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The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority?
Select one: