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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 poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be

left alone with her baby.

Choice B rationale

Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.

Choice C rationale

Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the

response is usually poor.

Choice D rationale

While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential

harm.

Correct Answer is B

Explanation

Choice A rationale

Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.

Choice B rationale

Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.

Choice C rationale

Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.

Choice D rationale

Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.

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