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 A
Explanation
Choice A rationale
A 37-year-old patient with obesity and pregnancy-induced hypertension presents multiple risk factors. Advanced maternal age, obesity, and hypertension collectively increase the
likelihood of complications such as preeclampsia, gestational diabetes, and cesarean delivery, necessitating close monitoring and management.
Choice B rationale
A patient with preexisting hypertension and twins is indeed high-risk due to the combined strain on the cardiovascular system and potential for preterm labor or other complications
associated with multiple gestations. However, the presence of pregnancy-induced hypertension and obesity in the first patient poses a slightly higher cumulative risk.
Choice C rationale
A 16-year-old patient with newly diagnosed gestational diabetes is at increased risk, particularly because of age and the potential for poorly managed diabetes leading to
complications. However, this scenario presents fewer immediate cumulative risks compared to older age and existing hypertension.
Choice D rationale
A 28-year-old patient who had a premature birth three years prior must be monitored for signs of recurrent preterm labor. Yet, this history alone does not present as high a cumulative
risk as older maternal age, obesity, and pregnancy-induced hypertension. .
Correct Answer is A
Explanation
Choice A rationale
Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of
membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.
Choice B rationale
Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling
discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.
Choice C rationale
Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent,
influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.
Choice D rationale
Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.