A newborn is diagnosed with hypoglycemia.

Which intervention should the nurse prioritize?

Administering IV insulin.

Encouraging frequent breastfeeding.

Monitoring blood pressure.

Administering a hypertonic saline solution.

Answer and Explanation

The Correct Answer is B

Encouraging frequent breastfeeding.

This is because breastfeeding provides glucose to the newborn baby, which can help prevent or treat hypoglycemia (low blood sugar). Hypoglycemia can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.

Choice A is wrong because administering IV insulin would lower the blood sugar level even more, which could be dangerous for the baby.

Choice C is wrong because monitoring blood pressure is not directly related to hypoglycemia.

Blood pressure may be affected by other factors such as stress, infection, or dehydration.

Choice D is wrong because administering a hypertonic saline solution would increase the sodium level in the blood, which could cause dehydration and electrolyte imbalance.

A hypertonic saline solution is not a source of glucose for the baby.

Normal ranges for blood glucose levels in newborns are between 47 to 85 mg/dL. Hypoglycemia is defined as blood glucose below 47 mg/dL.

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Correct Answer is D

Explanation

Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.

Phototherapy is effective when:

• The bilirubin levels decrease within 24 hours of treatment.

This means that the bilirubin is being cleared faster than it is being produced.

• The urine output and stool frequency increase during treatment.

This means that the bilirubin is being excreted through the kidneys and intestines.

• The skin color and muscle tone improve after treatment.

This means that the bilirubin is no longer causing jaundice or affecting the nervous system.

Statement A is wrong because it only describes one aspect of phototherapy effectiveness.

Statement B is wrong because it only describes another aspect of phototherapy effectiveness.

Statement C is wrong because it only describes the outcome of phototherapy effectiveness.

Statement D is correct because it includes all three aspects of phototherapy effectiveness.

Correct Answer is B

Explanation

This is because phototherapy can cause dehydration and increase insensible water loss, so covering the genitalia can prevent excessive fluid loss and maintain thermoregulation.

Some possible explanations for the other choices are:

• Choice A is wrong because monitoring skin temperature every hour is not enough to prevent hyperthermia or hypothermia during phototherapy.The skin temperature should be monitored continuously or at least every 15 minutes.

• Choice C is wrong because repositioning newborn every 4 hours is not frequent enough to prevent pressure ulcers, skin breakdown, or eye damage from the light source.The newborn should be repositioned at least every 2 hours.

• Choice D is wrong because encouraging parent-infant interaction as tolerated is not a specific intervention for phototherapy.

While parent-infant interaction is important for bonding and development, it should not interfere with the effectiveness of phototherapy.The newborn should be exposed to the light as much as possible, except for feeding and diaper changes.

Normal ranges for serum bilirubin levels vary depending on the age, gestational age, and risk factors of the newborn.Generally, the levels should be below 5 mg/dL for term infants and below 7 mg/dL for preterm infants by the fifth day of life.

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A newborn is diagnosed with hypoglycemia. Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating the effectiveness of phototherapy for a post-term infant who has hyperbilirubinemia due to ABO incompatibility with the mother’s blood type O negative and infant’s blood type B positive. Which of the following findings indicates that phototherapy is effective?

Correct Answer is D

Explanation

A nurse is planning care for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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A baby’s blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types?

A nurse is evaluating a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following outcomes indicates that the therapy is effective?

A newborn is diagnosed with hypoglycemia.

Which intervention should the nurse prioritize?