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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

PTB is the leading cause of neonatal mortality and for antenatal hospitalization. This is accurate because preterm birth (PTB) is a significant cause of infant mortality and often

requires extended hospital stays for the management of complications.

Choice B rationale

PTBs result in increased numbers of neonatal and infant deaths and long-term neurological impairment. This is accurate because preterm births are associated with higher rates of

mortality and long-term health issues in infants.

Choice C rationale

PTL is defined as regular uterine contractions resulting in cervical changes before 37 weeks gestation. This is accurate because preterm labor (PTL) is indeed characterized by these

symptoms occurring before full-term pregnancy.

Choice D rationale

Average costs for premature/low birthweight infants are more than 10 times as high than for other newborns. This is accurate because medical care for premature and low

birthweight infants is significantly more expensive due to the need for specialized care and extended hospital stays.

Correct Answer is B

Explanation

Choice A rationale

Labor dystocia involves prolonged labor. Her fast delivery history suggests the opposite, indicating rapid labor progress.

Choice B rationale

Rapid labor progression, frequent contractions, and previous short labors suggest she is at risk for precipitous labor, requiring immediate preparation for delivery.

Choice C rationale

Cephalopelvic disproportion indicates size mismatch between baby and pelvis, not rapid labor. Her history of quick deliveries does not align with this condition.

Choice D rationale

False labor typically involves irregular, less intense contractions. Her regular, intense contractions and labor history suggest active labor, not false labor.

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