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A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR 96.6°F (35.9°C), 158, 62, jittery, pink body with bluish hands and feet, crying.
Which of the following nursing actions is of highest importance?

A.

Swaddle the baby to provide warmth.

B.

Assess the glucose level of the baby.

C.

Take the baby to the mother for feeding.

D.

Administer the routine neonatal medications.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.

 

Choice B rationale

Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.

 

Choice C rationale

Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.

 

Choice D rationale

Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Postpartum psychosis is a serious mental health condition that can result in delusions and hallucinations. These symptoms increase the risk of harm to the infant, so it's essential that

the mother is not left alone with the baby to ensure both their safety.

Choice B rationale

Symptoms of postpartum psychosis typically last longer than one week and require medical intervention, contrary to what is stated in this choice. Treatment usually involves

antipsychotics, mood stabilizers, and sometimes hospitalization.

Choice C rationale

Clinical response to medications can be significant in many cases, and early and aggressive treatment often leads to improvement. This statement is inaccurate and does not reflect

the current understanding of postpartum psychosis treatment.

Choice D rationale

While monitoring vital signs is essential, it is not as critical as ensuring the infant's safety given the mother’s severe mental condition. The focus should be on psychiatric

management and safety protocols rather than routine vitals alone.

Correct Answer is C

Explanation

Choice A rationale

Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.

Choice B rationale

Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.

Choice C rationale

Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.

Choice D rationale

Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.

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