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.

Answer and Explanation

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.

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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.

A. Hypothermia, decreased muscle tone, and weak sucking reflex B. Excessive sleep, weak cry, and diminished grasp reflex C. Circumoral cyanosis, hyperactive Babinski reflex, and constipation D. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

Correct Answer is D

Explanation

Choice A rationale
Hypothermia, decreased muscle tone, and a weak sucking reflex are not typically exhibited by newborns whose mothers are substance abusers. These symptoms could be indicative of other medical conditions.
Choice B rationale
Excessive sleep, a weak cry, and a diminished grasp reflex are not the most common behaviors exhibited by newborns of substance-abusing mothers.
Choice C rationale
Circumoral cyanosis, a hyperactive Babinski reflex, and constipation are not typically seen in newborns of substance-abusing mothers. These symptoms could be indicative of other medical conditions.
Choice D rationale
Newborns of substance-abusing mothers often exhibit decreased amounts of sleep, a hyperactive Moro reflex, and difficulty feeding. These symptoms are related to withdrawal from the substances the mother was using during pregnancy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What action should the nurse take in anticipating the plan of care for this patient?

Correct Answer is A

Explanation

What behaviors are often exhibited by newborns whose mothers are substance abusers?

Correct Answer is D

Explanation

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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?