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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The Ballard tool does not assess behavioral maturity directly.
B. The reflexes are part of the neuromuscular system, but the tool assesses both neuromuscular and physical maturity.
C. The Ballard assessment tool evaluates both neuromuscular maturity (such as posture, square window sign, arm recoil) and physical maturity (such as skin, ear form, breast tissue) in neonates to assess gestational age.
D. Reflexes are part of neuromuscular maturity, but the tool combines both neuromuscular and physical components.

A. 9 B. 7 C. 6 D. 8

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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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?

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Naxlex Comprehensive Predictor Exams

The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?

Correct Answer is C

Explanation

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: pink body with blue hands and feet, heart rate 108 bpm. respiratory rate 36 per minute, some flexion, and a vigorous cry with stimulation. What does the nurse determine the baby's APGAR score to be?

Correct Answer is D

Explanation

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