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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Correct Answer is B

Explanation

Choice A rationale

While emergency cesarean birth preparation may be necessary in some cases, the primary focus should be on monitoring labor progression and the effects of oxytocin.

Choice B rationale

Monitoring the intensity, interval, and length of contractions is crucial in assessing the efficacy of oxytocin and ensuring the progress of labor while minimizing the risk of uterine hyperstimulation.

Choice C rationale

Checking the perineum for bulging is important in advanced labor stages but is not the primary focus when managing hypotonic dystocia and oxytocin administration.

Choice D rationale

Monitoring the client’s hourly blood pressure is important for overall health but is secondary to evaluating the contraction patterns and effectiveness of oxytocin in labor progression

A. Seizures. B. Stroke. C. Organ damage. D. Preterm birth.

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

Explanation

Choice A rationale

Seizures can occur due to severe preeclampsia, leading to eclampsia, characterized by generalized tonic-clonic seizures. Magnesium sulfate is often used to prevent seizures in these patients, alongside other monitoring measures.

Choice B rationale

Stroke risk is elevated in preeclamptic patients due to hypertension, endothelial dysfunction, and increased coagulation. Blood pressure control is essential to reduce stroke risk and manage preeclampsia complications effectively.

Choice C rationale

Organ damage, particularly to the liver and kidneys, is a complication of preeclampsia. Elevated liver enzymes and proteinuria indicate hepatic and renal involvement, necessitating close monitoring and potential intervention to mitigate damage.

Choice D rationale

Preterm birth is often a result of preeclampsia due to placental insufficiency and maternal health deterioration. Early delivery may be necessary to protect the well-being of both mother and fetus, highlighting the importance of timely diagnosis.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

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

Explanation

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