How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions.

Exhibits

Complete the diagram by dragging from the choices below to specify:

  • What condition the newborn is most likely experiencing.
  • Two actions the nurse should take to address that condition.
  • Two parameters the nurse should monitor to assess the newborn’s progress.

Answer and Explanation

The Correct Answer is []

Condition: Hypoglycemia.

2 actions:

Administer intravenous dextrose as prescribed,

Encourage breastfeeding to promote glucose stability.

2 parameters:

Blood glucose levels,

Muscle tone and reflexes.

Rationale for correct condition: The newborn's blood glucose level is critically low at 35 mg/dL, indicating hypoglycemia. Symptoms like jitteriness, decreased muscle tone, poor feeding, and irritability align with neonatal hypoglycemia. Hypoglycemia is common in newborns, especially with the stress of delivery. Early identification and treatment are crucial to prevent complications. The presence of hypoglycemia requires immediate intervention to stabilize the newborn's condition.

Rationale for actions: Administering intravenous dextrose is essential to quickly raise the newborn's blood glucose level. Dextrose provides a rapid source of glucose, addressing the immediate hypoglycemia. Encouraging breastfeeding promotes regular feeding, helping to maintain stable blood glucose levels over time. Frequent feeding supports glucose stability. Administering phototherapy treats hyperbilirubinemia, not hypoglycemia. Administering calcium gluconate addresses hypocalcemia, which is secondary here. Gastric lavage is unnecessary for feeding intolerance in this context.

Rationale for parameters: Monitoring blood glucose levels is critical to ensure the newborn's glucose levels remain stable. Frequent checks guide the effectiveness of treatment. Muscle tone and reflexes assess neurological responses and improvement with treatment. Changes can indicate recovery from hypoglycemia. Serum bilirubin levels are related to jaundice. Oxygen saturation is stable and unrelated to hypoglycemia. Serum calcium levels monitor hypocalcemia, not directly hypoglycemia.

Rationale for incorrect conditions: Neonatal Abstinence Syndrome presents with withdrawal symptoms, not primarily hypoglycemia. Neonatal sepsis would show signs of infection and systemic instability. Hyperbilirubinemia focuses on elevated bilirubin and jaundice.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

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

Explanation

  1. Jitteriness: Jitteriness can be seen in hypoglycemia (due to low blood sugar), neonatal sepsis (which causes systemic effects including jitteriness), and neonatal abstinence syndrome (due to withdrawal from maternal substances).
  2. Poor feeding: Poor feeding is consistent with hypoglycemia (due to low energy reserves), neonatal sepsis (due to general ill-health), and neonatal abstinence syndrome (as a withdrawal symptom).
  3. Petechiae on the chest: Petechiae is a sign of neonatal sepsis, which can result from bacterial infections or other causes affecting the clotting system. It is not typically seen in hypoglycemia, neonatal abstinence syndrome, or hyperbilirubinemia.
  4. Blood glucose 35 mg/dL: This is a hallmark sign of hypoglycemia, indicating a dangerously low level of glucose in the blood.
  5. High-pitched cry: A high-pitched cry is a classic symptom of neonatal abstinence syndrome, often seen in infants withdrawing from opioids or other substances. It is not a typical sign of hypoglycemia, neonatal sepsis, or hyperbilirubinemia.

Correct Answer is A

Explanation

Choice A rationale

Palpating the groin area is the correct method to check for an inguinal hernia. An inguinal hernia occurs when a portion of the intestine protrudes through a weak spot in the abdominal muscles into the groin area. This area should be carefully examined to identify any bulges or abnormalities that indicate a hernia.

Choice B rationale

Palpating the abdomen may be useful for identifying other conditions, such as abdominal distension or masses. However, it is not the most appropriate site for detecting an inguinal hernia, which specifically involves the groin area.

Choice C rationale

Palpating the lower back is not relevant for detecting an inguinal hernia. The lower back is not a common site for hernias, and examining this area would not provide information about the presence of an inguinal hernia.

Choice D rationale

Palpating the upper thigh is not the correct method to check for an inguinal hernia. While the inguinal region is located near the upper thigh, the hernia itself protrudes into the groin area. The upper thigh does not provide the necessary information to identify an inguinal hernia.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register