A nurse is assisting in the care of a newborn in the postpartum unit.
Complete the following sentence by using the lists of options.
The nurse should first address the newborn's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
? Rationale for Correct Answers
Glucose level is the priority because the newborn’s blood glucose is 35 mg/dL, which is below the normal threshold of 40–45 mg/dL. Neonatal hypoglycemia can lead to seizures, apnea, and brain injury if untreated. Immediate intervention is critical to prevent neurologic damage.
Feeding difficulties are the next concern because they contribute to poor caloric intake and perpetuate hypoglycemia. The newborn exhibits poor latch, uncoordinated suck, and loose stools—hallmarks of neonatal abstinence syndrome (NAS), which impair feeding and weight gain.
❌ Rationale for Incorrect Response 1 Options
Respiratory rate (65/min) is mildly elevated but within the upper limit of normal for newborns (30–60/min). No signs of respiratory distress (e.g., nasal flaring, retractions, grunting) are present, making this a lower priority.
Heart rate (165/min) is within the normal neonatal range (120–160/min). Mild tachycardia can be attributed to irritability or crying and is not immediately life-threatening.
Temperature (37.5°C) is within the normal range for newborns (36.5–37.5°C). There is no evidence of fever or hypothermia requiring urgent intervention.
❌ Rationale for Incorrect Response 2 Options
Skin findings such as mottling are nonspecific and often seen in NAS or immature autonomic regulation. They are not immediately dangerous.
Cry characteristics like high-pitched crying are typical of NAS but are not life-threatening and do not require urgent intervention.
Tremors are a common NAS symptom but are not acutely harmful unless associated with seizures, which are not reported here.
? Take-Home Points
- Neonatal hypoglycemia (<40 mg/dL) is a medical emergency requiring prompt correction to prevent neurologic injury.
- Feeding difficulties in NAS exacerbate hypoglycemia and must be addressed to ensure adequate caloric intake.
- NAS presents with autonomic, gastrointestinal, and neurologic symptoms; diagnosis is clinical and supported by maternal and neonatal drug screens.
- NAS must be differentiated from neonatal sepsis, hypoxic-ischemic encephalopathy, and metabolic disorders, which may present similarly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increased blood pressure is typically not a sign of fluid deficit, but rather can be a compensatory mechanism in early stages or indicate other conditions. In significant fluid imbalance due to nausea and vomiting, hypotension (decreased blood pressure) is more commonly observed as a result of reduced circulating volume.
Choice B rationale
Dry mucous membranes are a reliable indicator of dehydration and fluid volume deficit. When the body loses excessive fluids due to persistent nausea and vomiting, the oral mucosa becomes less hydrated and appears dry or tacky, reflecting reduced interstitial and intracellular fluid.
Choice C rationale
Elastic skin turgor indicates adequate hydration, as the skin quickly returns to its original position when pinched. In a client experiencing a fluid imbalance due to significant vomiting, one would expect to see decreased skin turgor, where the skin remains tented or slowly returns to normal.
Choice D rationale
Decreased heart rate is not a typical finding in fluid volume deficit. Rather, the body compensates for reduced circulating blood volume by increasing the heart rate (tachycardia) to maintain cardiac output and systemic perfusion, ensuring adequate oxygen delivery to tissues.
Correct Answer is B
Explanation
Choice A rationale
Vesicles on the skin, lips, and around the eyes are characteristic findings associated with herpes simplex virus infections, not Candida albicans. Herpes simplex presents with fluid-filled lesions and can be transmitted vertically during birth, manifesting in localized or disseminated forms in the neonate.
Choice B rationale
White patches on the tongue that cannot be removed are a classic sign of oral candidiasis, commonly known as thrush. This fungal infection, caused by *Candida albicans*, involves adhesion and proliferation of yeast on the mucous membranes, forming adherent pseudomembranous plaques.
Choice C rationale
Edematous red conjunctivae are typical manifestations of conjunctivitis, which can be caused by bacterial or viral infections, such as *Chlamydia trachomatis* or *Neisseria gonorrhoeae*, acquired during passage through the birth canal. This finding is not indicative of *Candida albicans* infection.
Choice D rationale
A temperature of 37.5° C (99.5° F) is within the normal range for a newborn, which typically falls between 36.5° C and 37.5° C (97.7° F and 99.5° F). While infections can cause fever, this specific temperature alone does not definitively indicate an infection with *Candida albicans* or any other pathogen.
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