Difficulty: Medium
Average Score: 79%
Simulated
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
Correct answer
A
Rationale
Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.