A three-hour-old newborn, of a gestational diabetic mother, is asymptomatic and successfully breastfed shortly after birth. The newborn's heelstick glucose level is 36 mg/dL (2.0 mmol/L). Which intervention should the nurse do first?

Initiate formula feeding.

Assist the mother to breastfeed the infant.

Give intravenous 10% dextrose in water.

Provide 1.125 oz (34 mL) of oral glucose.

Answer and Explanation

The Correct Answer is B

Choice A rationale

The newborn's heelstick glucose level is 36 mg/dL (2.0 mmol/L), which is below the normal range (40-60 mg/dL). While this indicates a need for intervention, formula feeding is not the first step because the newborn is asymptomatic and has successfully breastfed, suggesting that breastfeeding may still be an option to raise the glucose level.

Choice B rationale

The initial intervention for an asymptomatic newborn with a heelstick glucose level of 36 mg/dL is to encourage breastfeeding. Breast milk contains lactose, which is a sugar that can help raise the newborn's blood glucose levels naturally. Breastfeeding also promotes bonding and is a less invasive intervention than formula or IV dextrose.

Choice C rationale

Intravenous 10% dextrose is a more invasive intervention reserved for symptomatic newborns with hypoglycemia or those who do not respond to oral feedings. Since this newborn is asymptomatic and has already breastfed, a less aggressive approach is warranted as the first step.

Choice D rationale

Administering oral glucose is an appropriate intervention for hypoglycemia. However, since the newborn has already demonstrated an ability to breastfeed, assisting the mother to breastfeed again is the preferred initial approach because it is a natural and effective way to raise blood glucose levels.

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Correct Answer is A

Explanation

Choice A rationale

Applying a prescribed petroleum-based ointment or similar lubricant to the circumcision site after each diaper change is crucial for healing. This creates a protective barrier, preventing the raw glans from adhering to the diaper, which can cause pain and tissue damage upon removal. The ointment promotes a moist wound environment, which is conducive to optimal healing.

Choice B rationale

The umbilical cord and circumcision site are two separate areas of a newborn that require distinct care. Cleaning the umbilical cord first could introduce bacteria from one site to the other. To prevent cross-contamination and infection, it is essential to care for each area separately with clean supplies and to perform hand hygiene between each care procedure.

Choice C rationale

Using antiseptic baby wipes on the circumcision site is not recommended as the chemicals in the wipes can be irritating to the sensitive, healing tissue of the glans penis. Gentle cleaning with warm water and a soft cloth is the preferred method. Regular washing with harsh antiseptics can delay healing and cause discomfort.

Choice D rationale

Acetaminophen is an analgesic that may be prescribed for pain management, but it is not a routine part of circumcision site care. It is a medication given for pain relief, not a method of wound care. The primary care instructions focus on keeping the site clean and protected with ointment to promote healing and reduce the risk of infection.

A. Activation of the let down reflex. B. Return of the uterus to prepregnancy size. C. Stimulation of uterine contractions. D. Expulsion of the placenta. E. Expulsion of the placenta.

Correct Answer is C

Explanation

Choice A rationale

The let-down reflex is primarily mediated by oxytocin's effect on myoepithelial cells surrounding the alveoli in the mammary glands. This action causes milk ejection, not activation of the reflex itself. Prolactin is the hormone primarily responsible for milk production, while oxytocin's role is specifically in the mechanical release of the milk.

Choice B rationale

Involution, the process of the uterus returning to its pre-pregnancy size, is a gradual process that occurs over several weeks. While oxytocin's uterine contractions contribute to this process by compressing blood vessels and promoting uterine tone, it is not the immediate and primary outcome. This long-term process is influenced by many hormonal and physiological changes.

Choice C rationale

Oxytocin is a neuropeptide and a potent uterotonic agent. It works by binding to specific receptors on the smooth muscle cells of the myometrium, leading to increased intracellular calcium concentrations. This cascade of events triggers strong, rhythmic contractions, which are essential for labor induction and postpartum hemorrhage prevention.

Choice D rationale

While oxytocin-induced uterine contractions are crucial for the third stage of labor, which involves placental expulsion, the direct and primary action of the administered hormone is the stimulation of those contractions. The expulsion of the placenta is the clinical outcome resulting from the physiological action of the uterine muscle contracting.

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A three-hour-old newborn, of a gestational diabetic mother, is asymptomatic and successfully breastfed shortly after birth. The newborn's heelstick glucose level is 36 mg/dL (2.0 mmol/L). Which intervention should the nurse do first?

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Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include when teaching parents to care for their newborn's circumcision site?

Correct Answer is A

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Correct Answer is C

Explanation

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

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A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. Which intervention should the nurse implement first?

A three-hour-old newborn, of a gestational diabetic mother, is asymptomatic and successfully breastfed shortly after birth. The newborn's heelstick glucose level is 36 mg/dL (2.0 mmol/L). Which intervention should the nurse do first?

A client at 17-weeks gestation expels the products of conception in her bed. Which intervention is most important for the nurse to implement?