A nurse is caring for a newborn who is 4 hours old.

The newborn is lying in a bassinet, lightly swaddled.

The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis.
Respirations are rapid and unlabored.

What condition is the newborn most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the newborn’s progress?

Hypoglycemia

Neonatal Abstinence Syndrome

Cold Stress

Respiratory Distress Syndrome

Answer and Explanation

The Correct Answer is A

Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
Holding the finger above the heart prior to puncture does not affect the accuracy of a blood glucose test.
Choice B rationale
Smearing the blood onto the reagent strip can result in inaccurate readings.
Choice C rationale
Puncturing the finger while still damp with antiseptic solution can cause discomfort and potentially contaminate the sample.
Choice D rationale
Selecting the lateral side of the finger for puncture is recommended because it is less painful and has good blood flow.

A. Cleanse the site with povidone-iodine B. Monitor the rectal temperature every 4 hours . C. Prepare for surgical closure after 72 hours D. Administer broad-spectrum antibiotics

Correct Answer is D

Explanation

The correct answer is choice d. Administering broad-spectrum antibiotics.

Choice A rationale:

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

Choice B rationale:

Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.

Choice C rationale:

Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.

Choice D rationale:

Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.

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