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?
Swaddle the baby to provide warmth.
Assess the glucose level of the baby.
Take the baby to the mother for feeding.
Administer the routine neonatal medications.
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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Correct Answer is C
Explanation
Choice A rationale
Extension of the episiotomy is not a guideline for vacuum-assisted delivery. Episiotomy extension is considered based on perineal conditions during delivery, not as a primary
guideline for vacuum procedures.
Choice B rationale
Signs of fetal compromise resolving is critical for fetal safety but isn't specific to the guidelines for a vacuum-assisted delivery. Continuous fetal monitoring assesses for compromise,
not just vacuum application.
Choice C rationale
The "three-pull" rule refers to the number of attempts allowed with the vacuum to avoid excessive force and trauma. This guideline ensures safety during the procedure, preventing
overuse of vacuum pressure.
Choice D rationale
Full anesthesia status is unrelated to the guidelines for vacuum-assisted delivery. Anesthesia choices depend on patient and procedural needs, but aren't a guideline criterion for
vacuum use.
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.