A nurse is caring for a neonate in the neonatal intensive care unit (NICU).
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the newborn’s progress.
The Correct Answer is []
Hyperbilirubinemia
- Symptoms: The neonate does show signs of jaundice (yellowish skin), which is a symptom of hyperbilirubinemia. However, the primary concern here is the low blood glucose level (30 mg/dL), which is more immediately life-threatening and needs urgent attention.
- Diagnostic Results: The total serum bilirubin level is 5 mg/dL, which is elevated but not critically high. Hyperbilirubinemia might be a secondary concern, but the immediate symptoms and diagnostic results point more towards hypoglycemia.
Neonatal Abstinence Syndrome (NAS)
- Symptoms: NAS typically occurs in newborns exposed to addictive substances in utero, leading to withdrawal symptoms after birth. Common symptoms include irritability, high-pitched crying, tremors, and feeding difficulties.
- History: There is no mention of maternal substance use or withdrawal symptoms like frequent yawning or irritability. The jitteriness and poor feeding could overlap with NAS, but the history of gestational diabetes and the low blood glucose level make hypoglycemia a more likely diagnosis.
Summary
- Hypoglycemia: The neonate’s symptoms (jitteriness, lethargy, poor feeding) and the critically low blood glucose level (30 mg/dL) strongly indicate hypoglycemia. This condition is common in infants of diabetic mothers and large-for-gestational-age infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.
Correct Answer is C
Explanation
Choice A rationale
Wiping the cord daily with alcohol prep pads is not recommended. Current guidelines suggest keeping the cord clean and dry without the use of alcohol, as it can delay the natural drying and falling off process.
Choice B rationale
Keeping the cord moist is not recommended. The cord should be kept dry to promote natural drying and separation. Moisture can increase the risk of infection.
Choice C rationale
Folding the top of the diaper underneath the cord is recommended to keep the cord exposed to air and prevent irritation from urine or stool. This helps the cord dry out and fall off naturally.
Choice D rationale
Applying petroleum jelly to the cord stump is not recommended. The cord should be kept dry, and the use of ointments or creams can interfere with the natural drying process. .
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