Exhibits
A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct answers: Transient hypoglycemia is common in the first hours of life, especially in macrosomic infants due to maternal hyperglycemia-induced fetal hyperinsulinemia. Blood glucose <40–45 mg/dL is abnormal; this newborn had 35 mg/dL initially, improved to 50 mg/dL after feeding. Symptoms like jitteriness, abnormal cry, and mild hypotonia resolved post-breastfeeding. Breastfeeding provides lactose, which is hydrolyzed to glucose and galactose, correcting hypoglycemia physiologically. Early feeding is first-line for asymptomatic or mildly symptomatic neonates with glucose >25 mg/dL.
Rationale for incorrect Response 1 options: Signs of infection (e.g., temperature instability, poor feeding, lethargy) may overlap with hypoglycemia but require systemic signs and lab confirmation. This newborn improved with feeding and had no fever, tachypnea, or leukocytosis. Respiratory distress presents with grunting, nasal flaring, retractions, and desaturation. The newborn’s respiratory rate was normal (45/min), no distress signs noted. Hyperbilirubinemia manifests as jaundice, typically after 24 hours. No yellowing of skin or sclera was reported; phototherapy is not indicated.
Rationale for incorrect Response 2 options: Administer antibiotics is appropriate for suspected sepsis, not isolated hypoglycemia. No infectious signs or risk factors were present. Provide oxygen support is reserved for respiratory compromise. The newborn had stable vitals and no hypoxia. Initiate phototherapy treats elevated bilirubin. No bilirubin levels or jaundice signs were documented.
Take-home points:
- Transient neonatal hypoglycemia is common in macrosomic infants due to hyperinsulinemia.
- Early breastfeeding is the preferred intervention for mild hypoglycemia with stable vitals.
- Differentiate hypoglycemia from sepsis and respiratory distress using targeted clinical signs.
- Phototherapy is reserved for hyperbilirubinemia; not indicated without jaundice or elevated bilirubin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A nonstress test (NST) is a non-invasive prenatal test that monitors the fetal heart rate (FHR) in response to fetal movement. Accelerations of the FHR (increase of ≥ 15 beats per minute lasting ≥ 15 seconds) with movement over 20 minutes (reactive NST) indicate an intact fetal central nervous system and well-oxygenated fetus.
Choice B rationale
A typical NST usually takes about 20 to 40 minutes to complete. A prolonged duration of 2 to 4 hours is usually not necessary unless the fetus is initially inactive, requiring stimulation or extended monitoring to obtain a conclusive tracing. This duration suggests a misunderstanding of the expected procedure length.
Choice C rationale
An NST is generally performed for pregnancies deemed high-risk (e.g., post-dates, diabetes, hypertension, decreased fetal movement), not simply because it is the client's first pregnancy (primigravida). This statement indicates a misconception about the clinical indication for undergoing this specific fetal surveillance test.
Choice D rationale
The primary purpose of an NST is to assess fetal heart rate reactivity; it does not measure the strength or intensity of uterine contractions. Uterine contractions are measured by the tocodynamometer but their strength would be assessed using an internal uterine pressure catheter, which is not part of the standard NST procedure.
Correct Answer is D
Explanation
Choice A rationale
Calcium is essential for fetal bone and tooth development, as well as for maternal skeletal integrity, muscle function, and blood clotting. Although crucial, an increase in calcium intake (normal recommended intake is 1000 mg/day for most pregnant women) is primarily aimed at skeletal and cellular health, not specifically at the physiological increase in maternal blood volume, which necessitates increased erythrocyte production and plasma volume.
Choice B rationale
Vitamin E is an important fat-soluble antioxidant that protects cell membranes from oxidative damage and plays a role in red blood cell (RBC) integrity. While it is necessary for overall maternal and fetal health, its primary function is not directly linked to the significant expansion of maternal plasma and erythrocyte mass, which is the physiological basis for the approximately 30% to 50% increase in maternal blood volume during pregnancy.
Choice C rationale
Vitamin D is a fat-soluble vitamin critical for intestinal absorption of calcium and phosphorus, thereby maintaining optimal bone mineralization and immune function. Although supplementation is often necessary, especially in those with limited sun exposure (normal range 20-50 ng/mL), its primary role is in calcium homeostasis and immune function, not as a direct substrate for the substantial increase in maternal plasma volume and red blood cell mass during gestation.
Choice D rationale
Iron is a fundamental component of the heme group in hemoglobin, which is crucial for oxygen transport by red blood cells (RBCs). The approximately 45% increase in maternal blood volume during pregnancy requires a substantial increase in RBC production (erythropoiesis) to prevent dilutional anemia. Therefore, increased iron intake (normal recommended intake 27 mg/day) is vital for the necessary synthesis of hemoglobin to support this physiologic increase in maternal erythrocyte volume.
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