A full-term LGA infant is 3 hours of age and has a blood glucose level of 35 g/dL. The neonate appears to be trembling. Which of the following actions should the nurse perform at this time?
Tightly swaddle the baby.
Feed the baby formula or breast milk, and recheck the glucose 30 minutes after feeding.
Monitor the baby’s urinary output.
Transfer the infant to the NICU immediately.
The Correct Answer is B
Choice A rationale
Tight swaddling does not address hypoglycemia but may increase the infant’s stress. Hypoglycemia requires immediate correction through feeding or IV glucose, as low glucose levels can impair neonatal neurologic function.
Choice B rationale
Feeding provides immediate glucose replenishment, correcting hypoglycemia, which manifests as trembling. Rechecking glucose ensures effective correction. Normal neonatal glucose levels are 45–65 g/dL, with intervention needed below 40 g/dL.
Choice C rationale
Monitoring urinary output is insufficient for managing neonatal hypoglycemia. Trembling indicates an acute need for glucose, requiring prompt feeding or IV glucose rather than passive observation of output.
Choice D rationale
Immediate NICU transfer is unnecessary unless hypoglycemia remains uncorrected or other complications arise. Prompt feeding and glucose recheck are adequate to stabilize the neonate in most cases.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Engorgement is caused by milk overproduction or improper drainage rather than cracked nipples. While related to breastfeeding issues, it is not directly linked to cracked or bleeding nipples.
Choice B rationale
Mastitis is an infection of breast tissue that occurs due to milk stasis or blocked ducts. Cracked nipples increase infection risks, but mastitis is secondary to these infections.
Choice C rationale
Decrease in milk production is influenced by hormonal imbalances or poor latch rather than by cracked or bleeding nipples. It does not directly result from nipple trauma.
Choice D rationale
Cracked nipples create an entry point for bacteria, significantly increasing infection risks such as cellulitis or abscess formation. Proper hygiene and wound care are essential to reduce complications.
Correct Answer is A
Explanation
Choice A rationale
Postpartum depression with psychotic features may lead to suicidal ideation or infanticidal tendencies due to delusions or hallucinations. Ensuring safety is critical to prevent harm to both mother and infant.
Choice B rationale
Anger outbursts, though concerning, do not pose immediate threats like harm to self or infant. Addressing this behavior is secondary to prioritizing safety in severe postpartum psychosis cases.
Choice C rationale
Neglecting hygiene reflects depressive symptoms but does not indicate psychosis severity or imminent danger. Primary focus remains on managing safety risks to the mother and infant.
Choice D rationale
Losing trust in her husband is relevant to interpersonal stress but does not constitute a primary care concern. The immediate threat of harm takes precedence over marital dynamics.
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