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 C
Explanation
Choice A rationale
Retained placental fragments lead to delayed, not immediate, postpartum hemorrhage as they prevent complete uterine contraction over time.
Choice B rationale
Vaginal hematomas cause concealed, localized bleeding with minimal external blood loss, differing from profuse hemorrhage presentations.
Choice C rationale
Uterine atony, the most common cause, occurs when the uterus fails to contract effectively, leading to uncontrolled and excessive bleeding.
Choice D rationale
Uterine inversion, though serious, is rare and typically accompanied by visible uterine prolapse, not commonly causing profuse bleeding in the immediate postbirth period.
Correct Answer is D
Explanation
Choice A rationale
Preterm neonates lack developed mechanisms to shiver for thermogenesis, relying instead on non-shivering thermogenesis primarily through brown fat metabolism, which is underdeveloped in preterm infants.
Choice B rationale
The fetal position does not significantly affect heat retention in preterm neonates, as their thermoregulatory mechanisms depend on adequate fat stores and skin coverage.
Choice C rationale
Blood vessels in preterm neonates are closer to the skin's surface, increasing heat loss due to greater exposure and lack of insulating subcutaneous fat.
Choice D rationale
Preterm neonates have minimal body fat, impeding insulation and heat retention, leading to rapid heat loss, necessitating external warming measures like incubators or radiant warmers.
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