A nurse is caring for a newborn.
The newborn was delivered via cesarean birth approximately 1 hr ago.
The Apgar Scores are 8 and 9. Vitamin K was administered in the left vastus lateralis.
The weight is 4337 grams (9 lb 9 oz), length 52 cm (20.5 in), and gestational age assessment of 39 weeks. The newborn is large for gestational age and noted to be jittery and have decreased muscle tone. 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, and two parameters the nurse should monitor to assess the newborn’s progress.
Check the newborn’s capillary blood glucose level.
Place the newborn under a radiant warmer.
Monitor the newborn’s temperature.
Monitor the newborn’s color and frequency of bowel movements.
The Correct Answer is A,B,C
Choice A rationale
Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.
Choice B rationale
Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.
Choice C rationale
Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.
Choice D rationale
Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response, “You seem scared to talk to your parents,” is an empathetic response that validates the client’s feelings and encourages further communication. It’s important for the nurse to provide emotional support and help the client explore her feelings about the situation. The nurse can also provide information about confidentiality laws and discuss potential outcomes of various decisions.
Choice B rationale
Telling the client that her parents will have to be told why she is being admitted may not be accurate depending on the age of the client and local laws regarding minor’s rights to privacy in healthcare. It’s crucial to respect the client’s autonomy and privacy.
Choice C rationale
While it’s possible that the parents might understand, suggesting this puts pressure on the client to disclose her condition to her parents. The nurse should instead focus on supporting the client in making her own decision about disclosure.
Choice D rationale
Offering to tell the parents for the client could undermine the client’s autonomy and may not be legally permissible without the client’s consent. The nurse should instead focus on helping the client explore her options and come to her own decision.
Correct Answer is D
Explanation
Choice A rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. While NAS can pose risks to a newborn, it is not considered the greatest risk.
Choice B rationale
Developmental Dysplasia of the Hip (DDH) is a condition where the “ball and socket” joint of the hip does not properly form in babies and young children. While DDH can pose risks to a newborn, it is not considered the greatest risk.
Choice C rationale
Subgaleal hemorrhage is a rare but potentially lethal condition in newborns, usually resulting from vacuum-assisted delivery. While it can pose risks to a newborn, it is not considered the greatest risk.
Choice D rationale
Congenital cardiac defects are the most common type of birth defect. They can alter the way blood flows through the heart and pose a significant risk to a newborn.
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