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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 B

Explanation

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

Correct Answer is C

Explanation

Choice A rationale

Decreased pain level can be an effect of addressing the cause of pain, but it doesn't indicate improved uterine tone or resolution of atony.

Choice B rationale

Stable blood pressure is important, but it is not the direct outcome of improved uterine tone or the resolution of uterine atony.

Choice C rationale

A firm fundus at or below the umbilicus indicates successful contraction of the uterus, resolving uterine atony and reducing bleeding.

Choice D rationale

Reduced lochial flow can indicate decreased bleeding, but it does not directly indicate improved uterine tone or resolution of uterine atony.

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