Author Question: The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess ... (Read 51 times)

Beheh · **on:** Jun 28, 2018

The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first?

a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL
b. Term male newborn with a noted axillary temperature of 37.2 C (99 F)
c. 40-weeks' gestation female newborn with reported poor feed at last attempt
d. 39-weeks' gestation male newborn who has been crying prior to initial bath

Question 2

The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity?

a. The infant's arms and legs are extended.
b. There is some peeling and cracking of the skin.
c. There are few rugae on the scrotum and the testes are high in the scrotum.
d. The arm can be positioned with the elbow beyond the midline of the chest.

af · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification.

Answer to Question 2

ANS: B
Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age.