A nurse is caring for a newborn who has a blood glucose level of 40 mg/dL. Which of the following actions should the nurse take?

Encourage the mother to breastfeed the newborn.

Gavage feed 60 mL (2 oz) of glucose water.

Administer 10 mL of D5W via IV.

Recheck the glucose level in 2 hr.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Breastfeeding is the recommended first line of action for a newborn with a blood glucose level of 40 mg/dL, which is on the lower end of the normal range (normal range: 40-60 mg/dL for a newborn). Breast milk provides a natural source of glucose and other nutrients essential for the newborn's growth and development. It also facilitates bonding and has immunological benefits. Early initiation of breastfeeding helps to stabilize the blood glucose levels naturally.

Choice B reason:

Gavage feeding 60 mL of glucose water is not the first choice for managing borderline low blood glucose levels in a newborn. This method is typically reserved for infants who cannot feed orally due to medical conditions or prematurity. It is an invasive procedure and can be stressful for the newborn.

Choice C reason:

Administering 10 mL of D5W (5% dextrose in water) via IV is a treatment for hypoglycemia (low blood glucose levels), not for borderline low levels like 40 mg/dL. This intervention is usually considered when blood glucose levels are significantly lower than the normal range and the infant is symptomatic or unable to tolerate oral feedings.

Choice D reason:

Rechecking the glucose level in 2 hours is a passive approach and may not be appropriate for a newborn with a blood glucose level of 40 mg/dL. Immediate action, such as feeding, is preferred to prevent potential hypoglycemia and its associated risks.

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Correct Answer is A

Explanation

Choice A rationale:

Hormonal changes play a significant role in postpartum depression. After childbirth, there is a rapid decline in estrogen and progesterone levels, which can lead to mood fluctuations and depressive symptoms. Understanding this hormonal aspect is crucial for the nurse to address postpartum depression risk factors.

Choice B rationale:

Increased social support systems would be considered a protective factor against postpartum depression rather than a risk factor. Having strong social support can help mitigate the risk of developing postpartum depression.

Choice C rationale:

High self-esteem is not typically a risk factor for postpartum depression. In fact, individuals with higher self-esteem may be more resilient in coping with the challenges of postpartum period.

Choice D rationale:

Being a mother of two other children is not inherently a risk factor for postpartum depression. While having multiple children can be demanding, it does not directly increase the risk of developing postpartum depression. The hormonal changes and individual circumstances play more significant roles.

A. Hyporeactivity. B. Excessive high-pitched cry. C. Acrocyanosis. D. Respiratory rate of 50/min.

Correct Answer is B

Explanation

Choice A rationale:

Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.

Choice B rationale:

An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.

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A nurse is caring for a newborn who has a blood glucose level of 40 mg/dL. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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