1. An infant born at 37 weeks gestation, weighing 4.1 kg (9.04 pounds) is 2hours
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r old and appears large for gestational age, flushed, and tremulous. Which
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r procedure should the nurse follow to implement a glucose screening?
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(Arrange the examination process from first on top to last on the bottom.)
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1. Restrain the newborn's foot with your free hand.
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2. Cleanse the puncture site on the lateral aspect of the heel.
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3. Collect a spring-loaded automatic puncture device.
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,Page 2 of 32
Wrap the infant's foot with a heel warmer for 5 minutes Ans>1.Wrap the infant'sfoot
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with a heel warmer for 5 minutes.
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2. Collect a spring-loaded automatic puncture device.
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3. Restrain the newborn's foot with your free hand.
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4. Cleanse the puncture site on the lateral aspect of the heel.
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,Page 3 of 32
2. Which cardiovascular findings should the nurse assess further in a
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r clientwho is at 20-weeks gestation?
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a. Decrease in pulse rate. r r r
b. Decrease in blood pressure. r r r
c. Increase in heart sounds (S1, S2).
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d. Increase in red blood cell production Ans>a.Decrease in pulse rate.
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3. Which prescription should the nurse administer to a newborn to
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r reducecomplications related to birth trauma?
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a. Silver nitrate. r
b. Erythromycin.
c. Ceftriaxone.
d. Vitamin KAns>d.Vitamin K. r r
4. The nurse is assessing a full-term newborn's breathing pattern. Which
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, Page 4 of 32
findingsshouldthenurseassessfurther?(Selectallthatapply.)Selectallthatapply
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a. Shallow with an irregular rhythm.
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b. Chest breathing with nasal flaring.
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c. Diaphragmatic with chest retraction. r r r
d. Abdominal with synchronous chest movements.
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e. Rate of 58 breaths per minute.
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f. Grunting is heard with a stethoscope Ans>b.Chest breathing with nasal flaring.
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c.Diaphragmatic with chest retraction. r r r
f.Grunting is heard with astethoscope.
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