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
The hemoglobin level of 11.6 g/dL is within the normal range for a pregnant woman. While placenta previa requires monitoring, it is not immediately life-threatening.
Choice B rationale
Type 2 diabetes mellitus requires regular monitoring and management, but a single fasting blood glucose level does not indicate an immediate emergency unless it is extremely high or low.
Choice C rationale
Partial placental abruption can lead to significant complications for both the mother and fetus, including hemorrhage and fetal distress, making it the priority for immediate assessment.
Choice D rationale
An Rh-negative status and a recent cerclage placement are important for ongoing monitoring but do not present an immediate life-threatening condition that demands the first assessment.
Correct Answer is D
Explanation
Choice A rationale
Precipitous labor and birth are not directly associated with postpartum endometritis. The primary risk factors are related to infections during labor.
Choice B rationale
Postpartum endometritis is typically treated with a combination of antibiotics for 7-10 days, not a single dose of ampicillin or cephalosporin. A single dose would be insufficient for
treating the infection.
Choice C rationale
Postpartum endometritis is more common following cesarean birth due to increased risk of infection despite the use of sterile techniques during surgery.
Choice D rationale
Postpartum endometritis is associated with internal monitoring, amnioinfusion, prolonged labor, and prolonged rupture of membranes. These factors increase the risk of infection,
which can lead to endometritis.