When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
Hypothermia.
Deficient fluid volume.
Impaired gas exchange.
Risk for infection.
The Correct Answer is A
Choice A reason:
Hypothermia is the priority area for this newborn because the axillary temperature of 95.8° F (35.4° C) is below the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C) for newborns1. Hypothermia can lead to complications such as hypoglycemia, metabolic acidosis, and impaired oxygen delivery2. The nurse should initiate interventions to warm the newborn, such as skin-to-skin contact, radiant warmer, or swaddling2.
Choice B reason:
Deficient fluid volume is not the priority area for this newborn because the apical pulse of 114 beats per minute is within the normal range of 100 to 160 beats per minute for newborns345. A low pulse rate can indicate dehydration or shock in newborns2. The nurse should monitor the newborn's fluid intake and output, weight, and signs of dehydration, such as dry mucous membranes, sunken fontanels, and poor skin turgor2.
Choice C reason:
Impaired gas exchange is not the priority area for this newborn because the respiratory rate of 60 breaths per minute is within the normal range of 30 to 60 breaths per minute for newborns345. A high or low respiratory rate can indicate respiratory distress or failure in newborns2. The nurse should assess the newborn's breath sounds, chest movements, oxygen saturation, and signs of respiratory distress, such as nasal flaring, grunting, retractions, and cyanosis2.
Choice D reason:
Risk for infection is not the priority area for this newborn because there is no evidence of infection in the vital signs or the question stem. However, newborns are vulnerable to infection due to their immature immune systems and exposure to pathogens during birth and aftercare2. The nurse should follow infection control measures, such as hand hygiene, aseptic technique, and cord care, and educate the parents on how to prevent infection at home2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Changing the patient's gown may be necessary for comfort and hygiene, but it is not the priority after an amniotomy. The main concern is the well-being of the fetus and the mother.
Choice B reason:
Assessing the fetal heart rate is the priority after an amniotomy. This procedure involves rupturing the amniotic sac, which may lead to changes in the fetal environment. Monitoring the fetal heart rate helps determine if the baby is tolerating the procedure well and if there are any signs of distress.
Choice C reason:
Estimating the amount of amniotic fluid is essential during an amniotomy, but it is not the top priority. The focus should be on evaluating the fetal well-being first.
Choice D reason:
Assessing the color of the amniotic fluid is significant, but it is not the primary concern immediately after an amniotomy. While changes in fluid color may indicate certain conditions, the fetal heart rate assessment takes precedence in this situation.
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
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