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 C
Explanation
Choice A rationale
Joint pain is not a common side effect of the rubella immunization.
Choice B rationale
Breastfeeding is not typically contraindicated after receiving the rubella immunization.
Choice C rationale
Women are advised to avoid becoming pregnant for at least one month following the rubella immunization because the vaccine contains a live virus.
Choice D rationale
The rubella immunization is not typically given as a series of three immunizations.
Correct Answer is B
Explanation
Choice A rationale
The position of the uterine fundus is not directly related to the client’s ability to void effectively.
Choice B rationale
A client urinating 30 ml/h indicates that the client is able to void effectively. This is the minimum acceptable urine output in an adult client.
Choice C rationale
Not feeling the urge to urinate could indicate a problem such as urinary retention.
Choice D rationale
A distended bladder upon palpation could indicate urinary retention, which means the client is not voiding effectively.
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