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 C

Explanation

Choice A rationale

Hypertonia, tachycardia, and metabolic alkalosis are not associated with necrotizing enterocolitis (NEC). NEC is characterized by gastrointestinal symptoms and signs of systemic illness.

Choice B rationale

Hypertension, apnea, and ruddy skin color are not specific indicators of necrotizing enterocolitis (NEC). NEC primarily presents with gastrointestinal symptoms and systemic instability.

Choice C rationale

Abdominal distention, temperature instability, and bloody stools are classic signs of necrotizing enterocolitis (NEC). These symptoms indicate severe inflammation and potential bowel necrosis.

Choice D rationale

Scaphoid abdomen, no residual with feedings, and increased urinary output are not characteristic of necrotizing enterocolitis (NEC). NEC typically presents with abdominal distention and feeding intolerance. .

A. Large amount of swelling of the labia. B. Fundus three fingerbreadths above the umbilicus. C. Moderate lochia rubra. D. Swelling of the ankles and feet.

Correct Answer is B

Explanation

Choice A rationale

Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.

Choice B rationale

A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.

Choice C rationale

Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.

Choice D rationale

Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.

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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

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