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 A
Explanation
Choice A rationale
Administering a bolus of 2 ml/kg glucose 10% IV is important for hypoglycemia management, providing rapid glucose delivery. Normal blood glucose level for neonates is 45-90 mg/dL. Severe hypoglycemia requires immediate intervention.
Choice B rationale
Immediate feeding can stabilize blood glucose levels by providing a sustained energy source. Breastfeeding or formula feeding aids in maintaining glucose homeostasis, supporting neonatal metabolic needs and preventing hypoglycemia.
Choice C rationale
An echocardiogram is a non-invasive diagnostic test used to evaluate cardiac structure and function. It is not a priority intervention compared to managing hypoglycemia or respiratory distress, as it does not address immediate neonatal needs.
Choice D rationale
Monitoring for respiratory distress involves observing signs such as tachypnea, grunting, nasal flaring, and retractions. Early identification of respiratory issues is crucial in neonates to prevent complications like respiratory failure.
Choice E rationale
Applying dextrose gel inside the baby’s cheek can quickly raise blood glucose levels in cases of mild hypoglycemia. It is an effective short-term intervention for stabilizing blood glucose while preparing for further treatment.
Choice F rationale
Monitoring temperature every 30 minutes helps detect hypothermia or hyperthermia. Normal neonatal temperature is 36.5-37.5°C (97.7-99.5°F). Maintaining thermal stability is vital to prevent metabolic complications in newborns.
Choice G rationale
Contacting respiratory therapy for arterial blood gas (ABG) and oxygen therapy ensures proper oxygenation and ventilation. ABGs provide critical information on acid-base status, and oxygen therapy supports adequate tissue oxygenation.
Choice H rationale
Keeping the neonate in a warmer with bilirubin lights (phototherapy) treats hyperbilirubinemia by converting bilirubin into a water-soluble form for excretion. Normal bilirubin levels are <12 mg/dL in term neonates. It is not an immediate priority.
Choice I rationale
Transferring to a neonatal intensive care unit (NICU) provides specialized care, including advanced monitoring and interventions for critically ill neonates. NICUs have resources for managing complex medical conditions and ensuring optimal outcomes.
Choice J rationale
Measuring blood glucose levels is essential for assessing neonatal glucose status, especially in high-risk infants. Normal blood glucose levels for neonates are 45-90 mg/dL. Identifying hypoglycemia is critical for prompt treatment.
Correct Answer is C
Explanation
Choice A rationale
The obstetrician follow-up appointment is typically scheduled at 6 weeks postpartum, not 8 weeks. Accurate timing of follow-up visits is crucial for monitoring the mother's health and recovery.
Choice B rationale
While abstaining from sexual activities postpartum is generally advised, it is usually recommended until the 6-week follow-up appointment, not specified by the obstetrician's discretion.
Choice C rationale
Contacting the pediatrician if the baby is not breastfeeding well or has fewer wet diapers and stools is critical for early detection of feeding issues, dehydration, or other health concerns.
Choice D rationale
A lactation nurse visit is beneficial for breastfeeding support but does not cover the broader scope of postpartum care and monitoring the newborn's health. Comprehensive instructions are essential for new mothers.
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