A nurse is caring for a 4-hour-old newborn in the neonatal unit. The newborn exhibits symptoms of distress, including jitteriness and rapid respirations.
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The Correct Answer is []
Condition: Hypoglycemia
Actions: Feed the newborn immediately with breastmilk or formula. Obtain a capillary blood glucose reading.
Parameters: Blood glucose levels. Respiratory effort.
Rationale for correct condition: The newborn's blood glucose level is significantly low at 30 mg/dL. Symptoms like jitteriness, rapid respirations, and mottling are indicative of hypoglycemia. The newborn has not been fed since birth, which can cause low blood sugar. The temperature is slightly low, another sign of hypoglycemia. Immediate feeding can help stabilize blood glucose levels.
Rationale for actions: Feeding the newborn will raise the blood glucose level quickly. A capillary blood glucose reading is crucial to confirm the diagnosis and monitor effectiveness of the treatment. IV glucose might be necessary if the newborn cannot feed or if the blood glucose does not stabilize. Phototherapy and a radiant warmer are not required unless other conditions are present.
Rationale for parameters: Monitoring blood glucose levels ensures the newborn's hypoglycemia is addressed effectively. Respiratory effort must be monitored to ensure that the rapid respirations normalize with the correction of blood glucose levels. Serum bilirubin levels and skin integrity are not directly related to hypoglycemia.
Rationale for incorrect conditions: Congenital heart defect would likely present with more severe respiratory distress or cyanosis, not just acrocyanosis and jitteriness. Neonatal sepsis would present with signs of infection like fever or lethargy, neither of which is observed here. Neonatal abstinence syndrome would include symptoms such as irritability, high-pitched crying, and feeding difficulties, not specifically observed in this newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Taking breaks and walking at least once every hour during travel helps improve circulation and reduce the risk of blood clots, which is particularly important during pregnancy. It also helps prevent swelling and discomfort.
Choice B rationale
While wearing the shoulder harness snugly is essential, it is not the most critical instruction for travel during pregnancy. Ensuring frequent movement and proper hydration are more directly related to maternal and fetal well-being.
Choice C rationale
The lap belt should be positioned under the belly and across the hips, not over the abdomen, to prevent injury to the fetus in the event of a sudden stop or collision.
Choice D rationale
Moving the car seat forward, closer to the steering wheel, is not recommended during pregnancy. There should be adequate space between the abdomen and the steering wheel to prevent injury in case of an accident.
Correct Answer is B
Explanation
Choice A rationale
White blood cell count (WBC) is typically used to identify infection or inflammation, not anemia. Anemia is usually diagnosed with a complete blood count (CBC) focusing on hemoglobin and hematocrit levels. Increased WBC can indicate a body's response to infection, but it does not provide information about anemia.
Choice B rationale
Platelet count is indeed used to assess bleeding risk. Platelets are critical for blood clotting; low platelet count (thrombocytopenia) can lead to increased bleeding risk. Monitoring platelet levels is crucial, especially in pregnancy, to manage and mitigate potential hemorrhage or bleeding disorders.
Choice C rationale
Sedimentation rate, or erythrocyte sedimentation rate (ESR), is a non-specific test used to detect inflammation in the body. While it can be elevated in conditions like infections, autoimmune diseases, and cancers, it does not specifically check for signs of cancer. It measures the rate at which red blood cells settle in a tube over a specified period.
Choice D rationale
Urine specific gravity measures the concentration of urine. It is used to evaluate kidney function, hydration status, and other conditions but not directly to identify the risk of pregnancy-induced hypertension. Gestational hypertension is diagnosed through blood pressure measurements and associated symptoms, not urine concentration.
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