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A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?

A.

Place a pacifier in the baby's mouth.

B.

Check the baby's diaper.

C.

Have the mother feed the baby.

D.

Assess the respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.

 

Choice B rationale

Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.

 

Choice C rationale

Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.

 

Choice D rationale

Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

A respiratory rate of 18 breaths/min is normal and does not indicate magnesium toxicity or the need for calcium gluconate.

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range and does not suggest magnesium toxicity. This indicates adequate renal function.

Choice C rationale

Patellar reflexes rated at one indicate mild hyporeflexia, which can be a side effect of magnesium sulfate but does not necessitate immediate intervention.

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly elevated, indicating magnesium toxicity. Calcium gluconate is the antidote for magnesium toxicity and should be administered

promptly to prevent severe complications.

Correct Answer is B

Explanation

Choice A rationale

While massaging the fundus and ensuring IV access are correct initial actions, methylergonovine (Methergine) is typically used for patients without hypertensive history due to its

potential to raise blood pressure.

Choice B rationale

This option correctly identifies initial steps and appropriate medication. Carboprost-tromethamine (Hemabate) is effective in controlling postpartum hemorrhage and can be safely

used in patients with hypertension when oxytocin is insufficient.

Choice C rationale

Quantifying blood loss is essential but it is not an immediate priority when the patient is showing signs of significant bleeding and instability. Immediate intervention to control bleeding

takes precedence.

Choice D rationale

Assisting the patient to the restroom and then massaging the fundus overlooks the immediate need to control bleeding. This approach may delay necessary treatment and increase

the risk of further hemorrhage.

Choice E rationale

Straight catheterization and oxytocin maintenance are part of the management of postpartum hemorrhage but do not address the immediate need to ensure uterine contraction and

control active bleeding as effectively as the initial steps outlined in Choice B. .

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