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
Encouraging breastfeeding every 2 to 3 hours is contraindicated in HIV-positive mothers. Breastfeeding can transmit HIV to the infant despite maternal antiretroviral therapy, thus alternative feeding methods are recommended to prevent viral transmission.
Choice B rationale
Zidovudine administration within 6 to 12 hours after birth reduces the risk of perinatal HIV transmission. Early prophylaxis is crucial for preventing viral replication and reducing the likelihood of the infant acquiring HIV.
Choice C rationale
Administering antibiotics for 7 to 10 days is unnecessary unless there is evidence of bacterial infection. HIV-exposed infants need antiviral prophylaxis to prevent HIV transmission, not routine antibiotic treatment without specific indications.
Choice D rationale
Delaying the initial bath for 1 to 2 days is not recommended as it doesn't impact HIV transmission risk. Immediate skin cleansing can reduce exposure to maternal blood and bodily fluids, thus it’s standard practice to bathe newborns soon after birth.
Correct Answer is D
Explanation
Choice A rationale
Yogurt is not a significant source of folic acid, providing minimal contribution to the daily requirement needed during pregnancy.
Choice B rationale
Whole milk is not a substantial source of folic acid, contributing little to meeting the daily folic acid requirement for pregnant women.
Choice C rationale
Collard greens are rich in folic acid, but the client's dislike for green leafy vegetables makes them unsuitable in this context.
Choice D rationale
Strawberries are a good source of folic acid and can help meet the recommended daily intake for folic acid in pregnant women.
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