A nurse in the transition nursery is assigned to care for four recently delivered infants. Which infant should the nurse assess first?
Reference Range: Blood glucose/neonate [30 to 60 mg/dL (1.7 to 3.3 mmol/L)]
A full-term infant who has a 98.2° F (36.8° C) axillary temperature and needs a bath.
An infant with tachypnea, tachycardia, and a meconium stained cord,
A 38-week gestation infant whose mother wants to breastfeed now.
Infant of a diabetic mother who has a blood glucose level of 60 mg/dL (3.3 mmol/L).
The Correct Answer is B
Rationale:
A. A full-term infant who has a 98.2° F (36.8° C) axillary temperature and needs a bath: A temperature within the normal neonatal range is not concerning, and the bath can be safely delayed. This infant is stable and does not require immediate assessment.
B. An infant with tachypnea, tachycardia, and a meconium stained cord: Respiratory distress in the presence of meconium raises concern for meconium aspiration syndrome, which can rapidly compromise oxygenation. This infant is at the greatest risk for airway obstruction and requires prompt assessment and intervention.
C. A 38-week gestation infant whose mother wants to breastfeed now: A term infant initiating breastfeeding is expected and appropriate, and while feeding support is important, there are no urgent physiologic concerns requiring immediate assessment in this situation.
D. Infant of a diabetic mother who has a blood glucose level of 60 mg/dL (3.3 mmol/L): A blood glucose level of 60 mg/dL is within the acceptable neonatal range of 30–60 mg/dL. Although infants of diabetic mothers require close glucose monitoring, this value is stable and does not require urgent intervention at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Encourage the mother to increase frequency of breastfeeding: Encouraging more frequent feeds is important if weight loss exceeds the normal range or if feeding cues are not being met. In this case, the infant’s weight loss is within the expected 5–10% of birth weight during the first days of life.
B. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns helps assess hydration status and feeding effectiveness. However, since the weight loss is within the physiologic range, this step is not the most immediate action.
C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the provider is appropriate when weight loss is greater than 10% of birth weight or when the infant shows clinical signs of dehydration. In this case, the 6% loss is normal.
D. Inform and assure the mother that this is a normal weight loss: Normal neonatal physiology includes losing 5–10% of birth weight in the first 3–5 days due to fluid shifts, limited intake, and initial adaptation. The nurse should reassure the mother, explain that this is expected, and continue to encourage routine feeding and monitoring.
Correct Answer is B
Explanation
Rationale:
A. Ibuprofen should be used prophylactically to prevent febrile seizures: Antipyretics like ibuprofen or acetaminophen help reduce fever-related discomfort but do not prevent febrile seizures. Prophylactic use for seizure prevention is not recommended.
B. Reassure the parents that febrile seizures decrease as the child grows older: Febrile seizures are typically benign, occur between 6 months and 5 years of age, and most children outgrow them. Conveying this information reduces parental anxiety and provides reassurance
C. Avoid excessive visual stimuli because it can precipitate seizure activity: While some seizures (e.g., photosensitive epilepsy) can be triggered by visual stimuli, febrile seizures are triggered by fever, not light exposure.
D. Provide the child with a sponge bath for temperatures over 100.6°F (38.1°C): Sponge baths may help reduce discomfort from fever but do not prevent febrile seizures. This intervention is supportive rather than preventive or prognostic.
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