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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Erythromycin ointment is administered to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. Newborns are at risk for eye infections, which can lead to blindness if untreated. Erythromycin ointment provides effective prophylaxis.

Choice B rationale

Neomycin ointment is not indicated for prevention of ophthalmia neonatorum caused by Neisseria gonorrhoeae. It is primarily used for treating minor skin infections and not effective against eye infections in newborns.

Choice C rationale

Tetracaine eye drops are used as a local anesthetic for pain relief during minor eye procedures. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

Choice D rationale

Latanoprost eye drops are used to treat glaucoma by reducing intraocular pressure. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Correct Answer is C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

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A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

Correct Answer is A

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

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