A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
Obtain a blood glucose level.
Feed the infant glucose water (10%).
Administer oxygen.
Decrease environmental stimuli.
The Correct Answer is A
Choice A rationale
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Starting IV fluids is essential but not the priority in this situation. Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first.
Choice B rationale
Informing the anesthesia care provider is crucial because caffeine can affect anesthesia administration and increase the risk of complications, such as increased gastric acidity and delayed gastric emptying.
Choice C rationale
Ensuring preoperative lab results is important, but it is not the immediate priority compared to informing the anesthesia care provider about the caffeine intake, which directly impacts anesthesia management.
Choice D rationale
Contacting the obstetrician is necessary but secondary. The immediate priority is to inform the anesthesia care provider about the caffeine intake, which has direct implications for anesthesia and surgical safety.
Correct Answer is ["C","E","G","H"]
Explanation
Choice A rationale
Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.
Choice B rationale
Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.
Choice C rationale
Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.
Choice D rationale
Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.
Choice E rationale
Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.
Choice F rationale
Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.
Choice G rationale
Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.
Choice H rationale
Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.
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