A nurse is caring for a newborn who is 4 hours old in the maternity unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities, all of which are signs of low blood sugar. The newborn's large birth weight (4,366 g) further increases the risk of hypoglycemia. Immediate feeding is crucial to increase blood sugar levels, and phototherapy can help manage any potential jaundice, which is often associated with hypoglycemia.
Feeding the newborn is essential to provide glucose and stabilize blood sugar levels. Monitoring phototherapy ensures effective treatment of jaundice, which often coexists with hypoglycemia in newborns.
Assessing skin integrity is necessary to prevent complications from jaundice and ensure proper phototherapy response. Monitoring bilirubin levels helps track jaundice severity and the effectiveness of treatment.
Kernicterus, a severe form of jaundice, is less likely because the newborn's symptoms primarily indicate hypoglycemia. Neonatal Abstinence Syndrome, due to maternal drug use, typically involves different symptoms such as irritability, excessive crying, and poor feeding. Congenital Syphilis is ruled out as the mother was treated and tests for syphilis are negative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.
Choice B rationale
An empty bladder is required for the test only in late pregnancy to prevent bladder injury; however, in early pregnancy, a full bladder may be required to better visualize the uterus and amniotic fluid.
Choice C rationale
An x-ray is not typically used during the needle placement for amniocentesis. Ultrasound is the preferred method to guide the needle to avoid harm to the fetus and mother.
Choice D rationale
The test does not determine the volume of amniotic fluid; it is used primarily for genetic analysis, assessing fetal lung maturity, and diagnosing certain fetal infections.
Correct Answer is C
Explanation
Choice A rationale
Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.
Choice B rationale
Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.
Choice C rationale
Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.
Choice D rationale
Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.
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