HESI RN Maternity Exam 7n

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Question 1 of 5

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8Â° F (35.8Â° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

A. Place a pulse oximeter on the heel B. Swaddle the infant in a warm blanket C. Document the findings in the record D. Obtain a heel stick blood glucose level

Correct Answer: D

Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia. A heel stick glucose test is urgent to confirm and treat this condition.

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Similar Questions

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8Â° F (35.8Â° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client's adjustment to the disorder as an adolescent?

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HESI RN Maternity Exam 7n | Nurselytic

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