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:

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["36"]

Explanation

Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.

Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.

Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.

A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge. B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician. C. You will need to set up an appointment with your obstetrician in 8 weeks.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Routine pediatric check-ups typically occur 2–4 weeks after birth. This allows the pediatrician to monitor the baby's growth, development, and overall health, including weight gain and feeding patterns.

Choice B rationale

Home bilirubin lights are recommended for treating neonatal jaundice, a common condition in newborns. Bilirubin lights help lower bilirubin levels in the baby's blood, preventing potential complications like kernicterus.

Choice C rationale

Postpartum obstetrician appointments are usually scheduled 6–8 weeks after delivery to assess the mother's recovery, address any postpartum concerns, and provide guidance on contraception and future pregnancies.

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Naxlex Comprehensive Predictor Exams

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["36"]

Explanation

Correct Answer is ["A","B","C"]

Explanation

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Which action should the nurse take?

Which action is most important for the nurse to implement?

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