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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A soft uterus indicates uterine atony, a complication rather than a normal finding. Daily fundal palpation ensures involution but should result in a firm, not soft, uterus.
Choice B rationale
Passage of clots is common postpartum, but ongoing monitoring for excessive clotting is crucial as it may indicate retained placental fragments or incomplete uterine involution.
Choice C rationale
Decreased lochia does not indicate complications unless it is completely absent, which may suggest uterine or cervical obstruction and warrants further evaluation.
Choice D rationale
Increased lochia or bright red bleeding signifies secondary postpartum hemorrhage, often caused by retained placental tissue or subinvolution, requiring immediate medical attention.
Correct Answer is C
Explanation
Choice A rationale
Respiratory depression is less common in myelomeningocele unless secondary to severe neurological anomalies. It is not the primary risk mediator in this congenital condition.
Choice B rationale
Decreased cardiac output is not directly associated with myelomeningocele. This condition primarily affects the spinal cord and surrounding tissues rather than cardiovascular function.
Choice C rationale
Infection risk is high due to exposed neural tissue, making it the most significant concern. Infection can lead to meningitis, sepsis, and neurological deterioration if not properly managed.
Choice D rationale
Neurological damage is inherent to myelomeningocele but does not act as an external risk mediator. The focus is on preventing additional risks like infections to improve outcomes.
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