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A nurse is caring for a neonate in the neonatal unit.

Exhibits

Which of the following actions should the nurse take first?

A.

Administer a bolus of intravenous glucose.

B.

Reassess the neonate’s blood glucose level in 30 minutes.

C.

Initiate feeding with formula or breast milk.

D.

Place the neonate under a radiant warmer.

Answer and Explanation

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..

 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale

Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.

Choice B rationale

Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.

Choice C rationale

Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.

Choice D rationale

Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

  1. “The glans penis will appear red and have a yellow crust as it heals. Do not remove this.”
    • Essential: This is a normal part of the healing process.
  2. “Ensure the diaper is really tight to keep the gauze attached to the penis.”
    • Contraindicated: The diaper should be loose to avoid pressure on the circumcision site.
  3. “Notify your pediatrician if your baby has not voided in 24 hours.”
    • Essential: This could indicate a problem that needs medical attention.
  4. “Coat the glans penis with petroleum jelly and cover with gauze.”
    • Essential: This helps prevent the diaper from sticking to the circumcision site and aids in healing.
  5. “Check for bleeding every 4 hours for the first 24 hours and notify your pediatrician if there is bleeding at the circumcision site.”
    • Essential: Monitoring for bleeding is crucial to ensure there are no complications.

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