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 F

Explanation

Choice A rationale

Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.

Choice B rationale

While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.

Choice C rationale

Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.

Choice D rationale

While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.

Choice E rationale

Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.

Choice F rationale

Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.

A. Advise the mother to stop nursing and offer formula. B. Teach the mother to pump her breast. C. Advise the mother to discuss this with the newborn's pediatrician. D. Teach about newborn sleep and hunger patterns.

Correct Answer is D

Explanation

Choice A rationale

It is important to encourage breastfeeding rather than offering formula, especially if the mother wishes to breastfeed.

Choice B rationale

Pumping is not necessary at this time as the baby is just 4 hours old and establishing feeding patterns.

Choice C rationale

Consulting the pediatrician is not immediately necessary for this situation.

Choice D rationale

Teaching the mother about newborn sleep and hunger patterns is appropriate, as newborns often have irregular feeding schedules in the first few days. .

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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

A nurse is caring for a newborn who is 56 hours old.Vital signs at 0700: Heart rate 168/min, Respiratory rate 70/min, Temperature 36.1°C (97.0°F), Oxygen saturation 97%. The nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?

Correct Answer is F

Explanation

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Correct Answer is D

Explanation

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