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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Denying parents the ability to hold their infant can interfere with bonding. Physiologically stable infants on oxygen benefit from being held, as it supports emotional well-being and parent-infant attachment without compromising oxygen delivery.
Choice B rationale
Holding a physiologically stable infant during gavage feeding fosters bonding, reduces parental anxiety, and stabilizes the infant's physiological parameters, as tactile stimulation aids neurodevelopment without causing stress to the infant's cardiorespiratory system.
Choice C rationale
Handholding alone is insufficient to support bonding and emotional connection. Physiologically stable infants benefit from full body contact during feeding to promote warmth, comfort, and the release of calming hormones like oxytocin.
Choice D rationale
Physiologically stable infants do not experience increased stress during feeding when held. Holding provides comfort and reduces stress, improving the feeding experience and supporting parent-infant bonding and attachment.
Correct Answer is B
Explanation
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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