Level: Advanced
Difficulty: Hard
Subtopic: Newborn safety
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. Assessment…
Maternal-newborn nursing Clinical Judgment Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. Assessment data include central cyanosis that does not improve with stimulation. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.