A nurse is caring for a neonate in the neonatal unit.
Which of the following actions should the nurse take first?
Administer a bolus of intravenous glucose.
Reassess the neonate’s blood glucose level in 30 minutes.
Initiate feeding with formula or breast milk.
Place the neonate under a radiant warmer.
The Correct Answer is A
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse should administer a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing a baby on their back to sleep significantly reduces the risk of SIDS. This position helps keep the airway open and reduces the risk of suffocation.
Choice B rationale
There is no direct correlation between SIDS and the diphtheria, tetanus, and pertussis vaccines. Vaccines are safe and do not increase the risk of SIDS3.
Choice C rationale
SIDS rates have actually decreased over the last 10 years, largely due to public health campaigns promoting safe sleep practices.
Choice D rationale
Sleep apnea is not the main cause of SIDS. The exact cause of SIDS is unknown, but it is believed to be related to defects in the brain that control breathing and arousal from sleep.
Correct Answer is C
Explanation
Choice A rationale
Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.
Choice B rationale
Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.
Choice C rationale
Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.
Choice D rationale
Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.
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