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 C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

A. Erythromycin ointment. B. Neomycin ointment. C. Tetracaine eye drops. D. Latanoprost eye drops.

Correct Answer is A

Explanation

Choice A rationale

Erythromycin ointment is administered to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. Newborns are at risk for eye infections, which can lead to blindness if untreated. Erythromycin ointment provides effective prophylaxis.

Choice B rationale

Neomycin ointment is not indicated for prevention of ophthalmia neonatorum caused by Neisseria gonorrhoeae. It is primarily used for treating minor skin infections and not effective against eye infections in newborns.

Choice C rationale

Tetracaine eye drops are used as a local anesthetic for pain relief during minor eye procedures. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

Choice D rationale

Latanoprost eye drops are used to treat glaucoma by reducing intraocular pressure. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

Correct Answer is A

Explanation

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