The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority?
1. Obtain a blood calcium level.
2. Take the newborn's temperature.
3. Obtain a bilirubin level.
4. Place a pulse oximeter on the newborn.
1
Rationale 1: Tremors are the classic sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.
Rationale 2: Body temperature might be necessary to monitor, but another action takes priority for this newborn.
Rationale 3: Bilirubin level might be necessary to monitor, but another action takes priority for this newborn.
Rationale 4: Oxygen saturation might be necessary to monitor, but another action takes priority for this newborn.
You might also like to view...
A novice nurse who wants to provide culturally competent care will include which elements when caring for patients?
1. Acceptance and guidance 2. Knowledge and sympathy 3. Awareness and sensitivity 4. Understanding and approving
The physician explains to a patient that the frequent infections he has been experiencing are caused by insufficient production of antibodies and immune cells. The nurse is aware that the physician is describing what type of disorder?
a. Immune deficiency b. Autoimmune disease c. Opportunistic infection d. Recurrent infection
Which health care provider order should the nurse question?
1. Endotracheal suctioning every hour 2. Endotracheal suctioning as needed 3. Maintain NPO status while client is ventilated 4. Intake and output every 4 hours
Which of the following assessments would be most concerning to a nurse caring for a patient who was recently admitted to the unit after a right knee replacement?
1. Pedal pulses on the operative side are weak compared with those on the nonoperative side. 2. A small amount of serosanguineous drainage is noted on the dressing. 3. The intravenous pump is infusing normal saline at 100 mL/hr. 4. The patient has a Foley catheter that is draining clear yellow urine.