Zayn Reddy
Zayn Reddy is a newborn male who was born 3 minutes ago following a normal spontaneous vaginal delivery
at 38 weeks. The mother is a 37-year-old female Gravida 4 Para 3. The mother had gestational diabetes which
was treated with diet. She does plan to breastfeed and reports that she breastfed all of her other children.
The cord was clamped at 3 minutes and the infant is currently skin to skin with mom. APGAR at 1 minute was
8 (Acrocyanosis, Heart Rate 135/min, arms and legs flexed, respirations-slow and irregular, prompt response
to stimulation).
After receiving handoff report, the nurse should determine the client’s priority needs. Indicate if the client is
a high priority or low priority using each of the priority frameworks below.
, Safety and Risk Reduction
Your response:
©@ High priority
You correctly selected 2 of the 5 responses.
Your response is correct.
Maslow's Hierarchy of Needs Rationale:
Your response: The nurse should identify that this client is a high priority when using the Safety and Risk Reduction framework to organ
© High priority care. The client is an infant who is totally dependent on others for basic needs. Due to his developmental level and imm
needs for maintenance of warmth and protection from injury the nurse must provide continuous care and initiate safety
Your response is correct.
Rationale: Urgent vs Nonurgent
The nurse should identify that this client is a high priority when using Maslow's Hierarchy of Needs framework to organize client
Your response:
care. The infant is in the critical transition period from fetal to newborn circulation. His initial APGAR score indicates that he is
X Low priority
transitioning well, however continuous monitoring and support is necessary to promote stabilization and a successful transition to
the extrauterine environment. The infant is completely dependent on others to meet every physical need.
Your response is incorrect.
Rationale:
Airway, Breathing, Circulation
The nurse should identify that this client is a high priority when using the Urgent versus Nonurgent framework to organi
Your response: care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations. He is in the critical t
X Low priority period to extrauterine life and has urgent needs to establish and maintain wellbeing.
Your response is incorrect.
Chronic vs Acute / Stable vs Unstable
Rationale:
The nurse should identify that this client is a high priority when using the Airway, Breathing, Circulation framework to organize client Your response:
X Low priroity
care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations. This is a common respiratory
pattern as the newborn initiates respirations; however, it requires continuous monitoring and may require intervention if the pattern
does not improve. Transition to respiration is the most critical task in the first moments after birth.
Your response is incorrect.
Rationale:
The nurse should identify that this client is a high priority when using the Chronic vs Acute/Stable vs Unstable framewor
organize client care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations.
Zayn Reddy is a newborn male who was born 3 minutes ago following a normal spontaneous vaginal delivery
at 38 weeks. The mother is a 37-year-old female Gravida 4 Para 3. The mother had gestational diabetes which
was treated with diet. She does plan to breastfeed and reports that she breastfed all of her other children.
The cord was clamped at 3 minutes and the infant is currently skin to skin with mom. APGAR at 1 minute was
8 (Acrocyanosis, Heart Rate 135/min, arms and legs flexed, respirations-slow and irregular, prompt response
to stimulation).
After receiving handoff report, the nurse should determine the client’s priority needs. Indicate if the client is
a high priority or low priority using each of the priority frameworks below.
, Safety and Risk Reduction
Your response:
©@ High priority
You correctly selected 2 of the 5 responses.
Your response is correct.
Maslow's Hierarchy of Needs Rationale:
Your response: The nurse should identify that this client is a high priority when using the Safety and Risk Reduction framework to organ
© High priority care. The client is an infant who is totally dependent on others for basic needs. Due to his developmental level and imm
needs for maintenance of warmth and protection from injury the nurse must provide continuous care and initiate safety
Your response is correct.
Rationale: Urgent vs Nonurgent
The nurse should identify that this client is a high priority when using Maslow's Hierarchy of Needs framework to organize client
Your response:
care. The infant is in the critical transition period from fetal to newborn circulation. His initial APGAR score indicates that he is
X Low priority
transitioning well, however continuous monitoring and support is necessary to promote stabilization and a successful transition to
the extrauterine environment. The infant is completely dependent on others to meet every physical need.
Your response is incorrect.
Rationale:
Airway, Breathing, Circulation
The nurse should identify that this client is a high priority when using the Urgent versus Nonurgent framework to organi
Your response: care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations. He is in the critical t
X Low priority period to extrauterine life and has urgent needs to establish and maintain wellbeing.
Your response is incorrect.
Chronic vs Acute / Stable vs Unstable
Rationale:
The nurse should identify that this client is a high priority when using the Airway, Breathing, Circulation framework to organize client Your response:
X Low priroity
care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations. This is a common respiratory
pattern as the newborn initiates respirations; however, it requires continuous monitoring and may require intervention if the pattern
does not improve. Transition to respiration is the most critical task in the first moments after birth.
Your response is incorrect.
Rationale:
The nurse should identify that this client is a high priority when using the Chronic vs Acute/Stable vs Unstable framewor
organize client care. The client is exhibiting signs of respiratory distress, including slow and irregular respirations.
