Maternal-newborn nursing · practice question

A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data include blood glucose 35 mg/dL with jitteriness. Which nursing action should the nurse take first?

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Implement the final step of the care plan before assessing the client.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the finding and recheck at the end of the shift without further assessment.Document the client as stable without reassessment.

Answer and explanation

Correct answer

B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data include blood glucose 35 mg/dL with jitteriness. Which nursing action should the nurse take first?

Correct answer

Why

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