A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution.

Which of the following interventions should the nurse include in the plan?

Monitor blood glucose levels every hour until stable.

Administer glucagon subcutaneously as prescribed.

Discontinue IV dextrose when blood glucose reaches 60 mg/dL.

Feed breast milk or formula every four hours.

Answer and Explanation

The Correct Answer is A

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed. This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns. Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL. This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL. Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours. This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia. Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand. Breast milk or formula can also be supplemented with IV dextrose if needed.

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Correct Answer is C

Explanation

This is a sign of dehydration, which can be caused by phototherapy.Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn.The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.

Choice A is wrong because conjunctivitis is not a common complication of phototherapy.It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.

Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes.It is not a priority finding and usually resolves after phototherapy is discontinued.

Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention.It usually disappears within a few days after phototherapy is stopped.

Correct Answer is C

Explanation

Jitteriness and poor feeding are common signs of hypoglycemia in a newborn.

Hypoglycemia is when the level of sugar (glucose) in the blood is too low.

Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.

Choice A is wrong because hypertension and bradycardia are not typical symptoms of hypoglycemia in a newborn.

They may indicate other conditions such as heart problems or infection.

Choice B is wrong because diarrhea and vomiting are not specific symptoms of hypoglycemia in a newborn.

They may be caused by many other factors such as infection, food intolerance, or gastroesophageal reflux.

Choice D is wrong because hyperactivity and irritability are not usual symptoms of hypoglycemia in a newborn.

They may be signs of other conditions such as pain, hunger, or overstimulation.

Normal ranges for blood glucose levels in newborns vary depending on the age, gestational age, and feeding status of the baby.Most doctors consider blood glucose that is below 47 milligrams per deciliter (mg/dl) to be the definition of hypoglycemia in newborns.

However, some babies may need higher levels to prevent brain injury.

A doctor will monitor the blood glucose levels of a newborn at risk for hypoglycemia and treat accordingly.

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A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution.

Which of the following interventions should the nurse include in the plan?