A nurse is caring for a newborn who is 4 hours old in the Neonatal Intensive Care Unit (NICU).
Exhibits
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 []
• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.
Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.
Correct Answer is C
Explanation
Choice A rationale
Instructing the client to avoid urinary elimination until after administration is not necessary. The administration of dinoprostone does not interfere with the client’s ability to urinate.
Therefore, this action is not required.
Choice B rationale
Placing the client in a semi-Fowler’s position for 1 hr after administration is not a necessary action. While positioning can be important in certain medical procedures, there is no specific requirement for a semi-Fowler’s position in the administration of dinoprostone.
Choice C rationale
Verifying that informed consent is obtained prior to administration is a crucial step in any medical procedure, including the administration of dinoprostone. Informed consent ensures that the client is aware of the procedure, its purpose, and any potential risks or benefits. It is a legal and ethical requirement.
Choice D rationale
Allowing the medication to reach room temperature prior to administration is not a necessary action. There is no specific requirement for dinoprostone to be at room temperature before administration.
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