A nurse is caring for a neonate born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation.
Exhibits:
The nurse evaluates the data presented. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct condition: Hypoglycemia in neonates can present with jitteriness, low body temperature, and poor feeding. Normal blood glucose levels for neonates range from 40-60 mg/dL. The Ballard maturity rating of 37 weeks indicates that the neonate may have an immature glucose metabolism. Early recognition and treatment are crucial to prevent complications.
Rationale for correct actions:
- Giving dextrose solution orally quickly increases blood glucose levels. This provides an immediate source of glucose to the neonate.
- Performing a heel stick for blood glucose testing allows for accurate monitoring of glucose levels. Continuous assessment ensures timely intervention.
Rationale for correct parameters:
- Blood glucose levels: Monitoring ensures that the neonate maintains normal glucose levels (40-60 mg/dL). This helps prevent hypoglycemia-related complications.
- Temperature: Neonates with hypoglycemia often have low body temperature. Monitoring temperature aids in detecting and addressing hypothermia.
Rationale for incorrect conditions:
- Altered respiratory function: The neonate has normal respiratory rate and heart rate.
- Thermoregulation: Although temperature is low, the jitteriness is more indicative of hypoglycemia.
- Sepsis: No signs of infection such as fever or elevated white blood cell count are present.
Rationale for incorrect actions:
- Provide manual breaths with a bag-valve mask: Not necessary as the neonate's respiratory rate is normal.
- Administer intravenous antibiotics: No signs of infection or sepsis.
- Place the neonate under a radiant warmer: This addresses temperature but not blood glucose levels.
Rationale for incorrect parameters:
- Respiratory rate: Normal, does not indicate hypoglycemia.
- Oxygen saturation: No signs of respiratory distress.
- Bilirubin levels: Not relevant to the current symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.
Choice B rationale
Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.
Choice C rationale
Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.
Choice D rationale
Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.
Choice E rationale
Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.
Correct Answer is C
Explanation
Choice A rationale
Collecting a urine sample for dipstick analysis can identify urinary tract infections (UTIs) or other abnormalities. Dipstick tests detect leukocytes, nitrites, protein, and glucose, providing rapid results for initial screening of urinary issues.
Choice B rationale
Asking the client if she had sexual intercourse yesterday may help identify potential causes of urinary frequency, such as post-coital irritation. However, it does not directly address the irregular uterine contractions or possible infections.
Choice C rationale
Obtaining a midstream urine specimen for culture is crucial for diagnosing UTIs, which can cause urinary frequency and uterine irritability. Culturing urine identifies specific pathogens, guiding targeted antibiotic therapy to treat the infection.
Choice D rationale
Determining if she has a change in vaginal discharge can indicate infections or other conditions affecting the reproductive tract. However, it does not directly address the urinary frequency or irregular uterine contractions, making it less immediate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.