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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. 3-year-old walking on tiptoes: While some children may walk on their tiptoes occasionally, it's not necessarily a cause for concern unless it's persistent or accompanied by other developmental delays.
B. 1.5-year-old attempting to scribble: This is a typical stage for exploring hand and finger movements, leading to early attempts at drawing.
C. 5-month-old with whole hand grasp: At this age, infants use their whole hand to grasp objects, which is a normal developmental step before developing a more refined pincer grasp.
D. 3.5-month-old with diminished Moro reflex. The Moro reflex is a normal reflex in newborns that typically disappears by around 4 to 6 months of age. A diminished or absent Moro reflex before this age could indicate neurological concerns or developmental delays. Referral to a healthcare provider is necessary for further evaluation.
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