A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: Administering intravenous dextrose as prescribed is crucial to rapidly raise the newborn's blood glucose level from the critically low value of 35 mg/dL. This intervention addresses the immediate risk of hypoglycemia and helps stabilize the newborn's metabolic status.
Choice B rationale: Warming the newborn using skin-to-skin contact promotes thermoregulation, which is essential for maintaining body temperature and overall stability. Keeping the newborn warm supports metabolic processes and aids in reducing the risk of hypoglycemia and other complications.
Choice C rationale: Administering phototherapy immediately is not necessary unless bilirubin levels are significantly elevated. The primary concern here is hypoglycemia, not hyperbilirubinemia.
Choice D rationale: Monitoring blood glucose levels every 30 minutes ensures that the interventions to correct hypoglycemia are effective. Frequent monitoring helps identify any need for further adjustments to treatment.
Choice E rationale: Administering antibiotics to treat suspected neonatal sepsis is not indicated based on the current symptoms and diagnostic results. The primary issue is hypoglycemia, which requires prompt correction.
Correct Answer is A
Explanation
Choice A rationale
Erythema infectiosum, or fifth disease, typically begins with a "slapped cheek" rash on the face. This is often the first noticeable sign of the disease before the rash spreads to other parts of the body.
Choice B rationale
The rash associated with fifth disease does not usually start on the arms. The initial presentation is on the cheeks, which can later spread to the trunk and extremities.
Choice C rationale
It is uncommon for the rash of erythema infectiosum to initially appear on the legs. The characteristic facial rash precedes the spread of the rash to other areas.
Choice D rationale
While the rash may eventually spread to the back, it typically starts on the face. The "slapped cheek" appearance is a hallmark sign of fifth disease.
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