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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.
Choice B rationale
Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.
Choice C rationale
Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.
Choice D rationale
Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.
Correct Answer is B
Explanation
Choice A rationale
Wearing a loose-fitting bra does not help in managing mastitis. Proper breast support and continuing breastfeeding are important to keep the milk flowing and reduce inflammation.
Choice B rationale
Continuing to breastfeed helps to clear the infection and maintain milk supply. It ensures that the ducts are cleared, reducing inflammation and aiding recovery from mastitis.
Choice C rationale
Limiting fluid intake is not recommended. Adequate hydration is crucial to help with milk production and overall recovery, especially during an infection.
Choice D rationale
An abdominal sonogram is not relevant to the management of mastitis. Treatment focuses on antibiotics, pain relief, and continued breastfeeding. .
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