Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry.
What is the top priority nursing action?
Notify the clinician immediately.
Test the blood glucose level.
Start an intravenous line with D5W.
Document the event in the nurse’s notes.
The Correct Answer is B
Choice A rationale
Notifying the clinician immediately may be necessary, but it is not the first action to take. The nurse should first identify the cause of the baby’s symptoms.
Choice B rationale
The baby’s symptoms are indicative of hypoglycemia, a common condition in infants of mothers with diabetes. Testing the blood glucose level would confirm this diagnosis and allow for appropriate treatment.
Choice C rationale
Starting an intravenous line with D5W may be necessary if the baby’s blood glucose level is low. However, the first step should be to confirm the diagnosis by testing the blood glucose level.
Choice D rationale
Documenting the event in the nurse’s notes is important, but it is not the first action to take. The nurse should first address the baby’s immediate needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a patient in active labor has a recent outbreak of genital herpes with verified lesions on the perineum, the nurse should prepare the patient for a cesarean delivery. This is to prevent transmission of the herpes virus to the baby during delivery.
Choice B rationale
While taking a culture of the lesions could help verify the involved organism, it would not change the immediate plan of care for this patient. The presence of active lesions necessitates a cesarean delivery regardless of the specific strain of the virus.
Choice C rationale
Asking the patient if she has had unprotected sex since her outbreak would not directly impact the plan of care in this situation. The primary concern is preventing transmission of the virus to the baby during delivery.
Choice D rationale
Using internal electronic fetal surveillance to determine a baseline fetal heart rate is generally avoided in patients with active genital herpes lesions, as this could potentially increase the risk of transmitting the virus to the baby.
Correct Answer is C
Explanation
Choice A rationale
In infants with asymmetric intrauterine growth restriction (IUGR), not all body parts appear proportionate. Typically, the head is disproportionately larger compared to the rest of the body.
Choice B rationale
While the extremities can be smaller in infants with IUGR, this is not specific to asymmetric IUGR910.
Choice C rationale
In asymmetric IUGR, the head seems large compared with the rest of the body. This is because the body slows its growth to allow the brain to continue growing.
Choice D rationale
One side of the body appearing slightly smaller than the other is not a typical characteristic of asymmetric IUGR910.
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