A nurse is assisting with the care of a newborn who is 4 hr old.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Potential Condition: Hypoglycemia
- Rationale: The jitteriness and weak cry can be signs of hypoglycemia, which is common in newborns, especially those with higher birth weights or whose mothers have diabetes or, in this case, a history of substance use during pregnancy.
Actions to Take:
1. Reinforce with the parent to feed the newborn: Feeding can help to stabilize the newborn's blood sugar levels.
2. Anticipate a prescription to obtain a capillary blood sample: This will confirm the diagnosis by measuring the newborn's blood glucose levels.
Parameters to Monitor:
1. Temperature: To ensure the newborn maintains a normal body temperature, as hypothermia can be associated with hypoglycemia.
2. Respiratory status: To monitor for any changes that could indicate worsening of the condition or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.
Correct Answer is D
Explanation
A. Leukorrhea, a normal increase in vaginal discharge, is a common and expected finding during pregnancy. It usually does not require immediate medical intervention unless accompanied by other symptoms.
B. Gingivitis is a common issue during pregnancy due to hormonal changes, but it is generally managed with good oral hygiene and routine dental care. It is not an urgent finding compared to other conditions.
C. Varicose veins are a common condition during pregnancy due to increased blood volume and pressure on the veins. While they can be uncomfortable, they are generally managed through lifestyle changes and do not represent an immediate risk.
D. Dysuria, or painful urination, may indicate a urinary tract infection or another serious condition that requires prompt medical attention. It can lead to complications if untreated, so it is a priority finding that needs to be reported to the provider for further evaluation and treatment.
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