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 C
Explanation
Choice A rationale
Tretinoin should be applied to the face after it has been cleaned and dried, but a longer wait time than 5 minutes may be recommended to ensure the skin is completely dry.
Choice B rationale
Using a dime-sized amount might be too little or too much depending on the treatment area. Specific application instructions should be based on professional guidance.
Choice C rationale
Using sunscreen with an SPF of 15 or higher is essential when using tretinoin as it makes the skin more sensitive to sunlight, increasing the risk of sunburn and damage.
Choice D rationale
Tretinoin is generally applied at night because it can make the skin more sensitive to sunlight. Applying it in the morning could lead to increased photosensitivity and risk of skin irritation.
Correct Answer is A
Explanation
Choice A rationale
Wooden building blocks are appropriate for infants with pneumonia as they are safe, can be easily sanitized, and allow the child to engage in quiet play without exerting too much physical energy.
Choice B rationale
Alphabet flash cards are not suitable for an infant, as they are geared towards older children who are learning letters and words.
Choice C rationale
Colored paper and safety scissors are not appropriate for infants due to the risk of choking on small pieces of paper and the potential danger of using scissors.
Choice D rationale
Stringing beads are not suitable for infants as they pose a choking hazard and require fine motor skills that infants have not yet developed.
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