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 B
Explanation
A. Nausea is a common side effect of terbutaline but does not typically require urgent reporting. It can be managed with supportive care or adjustments in therapy.
B. Crackles in the lungs are a serious side effect of terbutaline, which can cause pulmonary edema due to fluid retention. This finding indicates a potential adverse reaction that must be reported to the provider for further evaluation and management.
C. Dizziness can occur with terbutaline use but is not as immediately concerning as other potential side effects. It may be managed by adjusting the dose or monitoring the client.
D. Tremors are a common and less severe side effect of terbutaline, typically caused by its beta-adrenergic effects. While they are uncomfortable, they are not an immediate concern compared to more severe reactions.
Correct Answer is C,E,A,B,D
Explanation
1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.
2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.
3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.
4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.
5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.
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