A nurse admitted a neonate born less than 2 hours ago to a mother with gestational diabetes. The neonate weighs 4.5 kg. What is the priority nursing action for this neonate?
Perform a gestational age assessment to confirm risk factors.
Obtain a glucose level on the neonate via a heelstick.
Perform assessment under a radiant warmer.
Feed the neonate 30mL of formula or glucose water.
The Correct Answer is B
A. While important, assessing gestational age is not the priority over identifying hypoglycemia.
B. Infants of mothers with gestational diabetes (especially those with macrosomia >4 kg) are at risk for hypoglycemia. Monitoring glucose levels immediately is essential to detect and manage low blood sugar.
C. Temperature regulation is important but secondary to monitoring glucose in this scenario.
D. Feeding may be necessary, but glucose monitoring guides the decision for feeding or other interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid during or after delivery, leading to respiratory distress. This newborn has several findings consistent with MAS:
Dark brown-greenish amniotic fluid during labor indicates meconium-stained fluid.
Fine crackles throughout lung fields and expiratory grunting suggest impaired gas exchange and possible airway obstruction.
Rapid and shallow respirations (80/min) and the presence of green-stained vernix and fingernails further support this diagnosis.
Jaundice, hypoglycemia, and cold stress are also potential complications in newborns but are not the most immediate threats based on this newborn's clinical presentation.
Correct Answer is D
Explanation
A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
B. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
C. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
D. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
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