A nurse is caring for a newborn whose blood glucose level is 40. Which of the following interventions has priority in the nurse's plan of care?

Evaluate glucose levels again in 4 hours.

Assess for hypothermia.

Notify MD on call.

Evaluate blood serum glucose.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.

Choice B rationale

Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.

Choice C rationale

Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.

Choice D rationale

Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale

Respiratory assessment is important but not immediately concerning without specific abnormal findings.

Choice B rationale

Hemoglobin level of 9 g/dL is low and could indicate postpartum hemorrhage or anemia, warranting attention.

Choice C rationale

Heart rate abnormalities would be significant but are not provided in the data given.

Choice D rationale

Constant trickle of blood at the vagina suggests ongoing bleeding which could indicate a postpartum hemorrhage, requiring prompt intervention.

A. Clear fluid oozing out of the pilonidal sinus. B. Positive hip click bilaterally. C. Erythema toxicum on the torso. D. Limited abduction of the affected hip.

Correct Answer is D

Explanation

Choice A rationale

Clear fluid oozing from a pilonidal sinus is unrelated to congenital hip dysplasia and more associated with other conditions like pilonidal cysts.

Choice B rationale

A positive hip click can indicate hip instability but is not definitive for congenital hip dysplasia.

Choice C rationale

Erythema toxicum is a benign, self-limiting skin condition and does not relate to hip dysplasia.

Choice D rationale

Limited abduction of the hip is a key sign of congenital hip dysplasia, indicating restricted movement due to abnormal hip joint development. .

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A nurse is caring for a newborn whose blood glucose level is 40. Which of the following interventions has priority in the nurse's plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

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Correct Answer is D

Explanation

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