A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?
Place the newborn in a radiant warmer.
Monitor the newborn's blood pressure.
Initiate phototherapy.
Obtain blood glucose by heel stick.
The Correct Answer is D
Choice A rationale
Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.
Choice B rationale
Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.
Choice C rationale
Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.
Choice D rationale
Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Respiratory assessment is crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.
Choice B rationale
Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.
Choice C rationale
A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.
Choice D rationale
A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.
Correct Answer is []
Explanation
Condition: Neonatal Jaundice.
2 actions:
Initiate phototherapy,
Encourage frequent breastfeeding or formula feeding.
2 parameters:
Serum bilirubin levels,
Blood glucose levels.
Rationale for correct condition: Neonatal jaundice is indicated by the elevated bilirubin levels and yellow discoloration of the skin and sclera. The newborn's symptoms of lethargy, decreased muscle tone, and poor feeding are consistent with jaundice. Jaundice is common in newborns and requires prompt treatment to prevent complications like kernicterus. The total bilirubin level of 15 mg/dL is significantly elevated and needs intervention.
Rationale for actions: Initiating phototherapy helps lower bilirubin levels by breaking down bilirubin in the skin. This treatment is effective and commonly used for neonatal jaundice. Encouraging frequent breastfeeding or formula feeding promotes regular bowel movements, which help eliminate bilirubin from the body. Adequate feeding is essential to reduce jaundice severity. Administering intravenous dextrose addresses hypoglycemia but does not directly treat jaundice. Performing a lumbar puncture is unnecessary unless sepsis is suspected. Naloxone is used for opioid withdrawal, not jaundice.
Rationale for parameters: Monitoring serum bilirubin levels tracks the effectiveness of phototherapy. This parameter is crucial for assessing jaundice severity and treatment response. Blood glucose levels should be monitored due to the initial low reading, ensuring the newborn's glucose levels stabilize. Respiratory rate is normal and not directly related to jaundice. Urine output monitors hydration but is less specific to jaundice. Heart rate is stable and not a primary focus.
Rationale for incorrect conditions: Neonatal hypoglycemia focuses on low blood glucose but doesn't explain jaundice. Neonatal sepsis presents with more systemic signs like fever or abnormal reflexes. Neonatal abstinence syndrome involves withdrawal symptoms from maternal substance use, not relevant here.
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