A nurse in the newborn nursery is caring for a group of newborns.
Which of the following newborns requires immediate intervention?

A newborn who is 12 hours post-delivery and has a temperature of 37.0°C (98.6°F).

A newborn who is 27 hours post-delivery and has not voided.

A newborn who is 18 hours post-delivery and has not passed meconium.

A newborn who is 18 hours post-delivery and has acrocyanosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.

Choice B rationale

A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.

Choice C rationale

A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.

Choice D rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.

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Correct Answer is A

Explanation

Choice A rationale

Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.

Choice B rationale

While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..

Choice C rationale

Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..

Choice D rationale

While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..

A. Apply 1-2 cm ribbon from outer to inner canthus. B. Apply 2-3 inch ribbon from inner to outer canthus. C. Apply 1-2 cm ribbon from inner to outer canthus. D. Apply 1-2 inch ribbon to upper eyelid.

Correct Answer is C

Explanation

Choice A rationale

Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.

Choice B rationale

Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.

Choice C rationale

Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.

Choice D rationale

Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.

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A nurse in the newborn nursery is caring for a group of newborns.Which of the following newborns requires immediate intervention?

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A nurse in the newborn nursery is caring for a group of newborns.
Which of the following newborns requires immediate intervention?