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 D

Explanation

Choice A reason:

Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

Choice B reason:

Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.

Choice C reason:

Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.

Choice D reason:

This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

A. Gravida 3, Para 2. B. Gravida 3, Para 3. C. Gravida 4, Para 2. D. Gravida 4, Para 3.

Correct Answer is C

Explanation

Choice A rationale:

Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has

been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)

Choice B rationale:

This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

Choice C rationale:

This is the correct choice, as explained above. Choice D rationale:

This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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