Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Apply a pulse oximeter to the foot

Draw arterial blood gases.

Obtain a capillary blood glucose.

Provide blow by oxygen.

Answer and Explanation

The Correct Answer is C

A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Assess daily alcohol intake: Alcohol misuse can contribute to a variety of psychiatric symptoms, including hallucinations or delusions. Older adults may metabolize alcohol differently, leading to higher susceptibility to its effects. While this is important, it may not be the first priority unless there are clear signs of alcohol misuse (e.g., smell of alcohol, history provided by the client or family).

B. Identify signs of depression: Depression in older adults can sometimes present with psychotic features, including hallucinations or delusions. Understanding the client's emotional state and identifying symptoms of depression can provide insight into the cause of their behaviour. Depression is common in older adults and can be a precursor or a component of other psychiatric conditions.

C. Determine cognitive status: Cognitive impairment (e.g., dementia) can often present with hallucinations or delusions, and evaluating cognitive status can help differentiate between different types of disorders (e.g., dementia vs. primary psychotic disorders). Assessing cognitive function helps in identifying conditions like Alzheimer's disease or other dementias where hallucinations can be a symptom. This assessment can guide the further direction of evaluation and treatment, making it a critical first step.

D. Review risk factors for abuse: Older adults are at risk of abuse, which can include physical, emotional, and financial abuse. Identifying these risk factors is crucial for their safety and well-being. While this is a significant concern, unless there are immediate signs or disclosures of abuse, it may not be the most urgent assessment in the context of hallucinations.

A. Needle aspiration of the synovial space. B. Knee arthroplasty surgery. C. History of a fractured patella. D. Degenerative disease.

Correct Answer is D

Explanation

A. Needle aspiration of the synovial space: Needle aspiration of the synovial space is a diagnostic procedure used to collect synovial fluid for analysis. It is not directly related to crepitation.

B. Knee arthroplasty surgery: Knee arthroplasty (joint replacement surgery) involves replacing damaged knee joint components with artificial ones. While it can improve joint function, it is not directly related to crepitation.

C. History of a fractured patella: A fractured patella (kneecap) can lead to altered joint mechanics and abnormal wear. This might lead to long-term issues but isn't directly associated with crepitation unless it caused secondary degenerative changes in the knee joint.

D. Degenerative disease: Degenerative joint diseases like osteoarthritis often involve changes in the cartilage, leading to rough surfaces within the joint. When these rough surfaces rub against each other during movement, crepitation can occur.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

Correct Answer is C

Explanation

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

Correct Answer is D

Explanation

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Which assessment finding of an older adult client should the nurse associate with normal aging?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?