The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what?
Hypoglycemia
Renal failure
Necrotizing enterocolitis
Respiratory distress syndrome
The Correct Answer is A
A. Hypoglycemia: Tremors and a weak cry in a late preterm infant are classic early signs of low blood glucose. Infants born at 36 weeks have limited glycogen stores and immature metabolic regulation, making them vulnerable to hypoglycemia in the first hours to days of life.
B. Renal failure: Renal failure in neonates typically presents with decreased urine output, fluid retention, and electrolyte imbalances rather than tremors and weak cry. While preterm infants are at risk for renal complications, these neurologic signs point to metabolic disturbances.
C. Necrotizing enterocolitis: NEC usually manifests with feeding intolerance, abdominal distention, bloody stools, and lethargy. Tremors and weak cry are not characteristic early indicators of NEC.
D. Respiratory distress syndrome: RDS presents primarily with tachypnea, grunting, nasal flaring, and retractions due to surfactant deficiency. Neurologic symptoms like tremors and weak cry are not typical initial signs, making RDS an unlikely explanation for the findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["120"]
Explanation
Calculation:
Flow rate = 120 mL/hr.
Drop factor = 60 gtt/mL.
- Calculate the infusion rate in drops per minute (gtt/min).
Infusion rate (gtt/min) = (Flow rate (mL/hr) x Drop factor (gtt/mL)) / 60 minutes/hr
= (120 mL/hr x 60 gtt/mL) / 60 minutes/hr
= 120 gtt/min.
Correct Answer is B
Explanation
A. Report the discrepancy to the pediatrician immediately: While significant or excessive weight loss should be reported, mild physiologic weight loss in the first few days of life is expected. Immediate reporting is not necessary if the loss is within the normal range of 5–10% of birth weight.
B. Decrease the interval between the infant's feedings: Newborns typically lose some weight in the first 3–5 days due to fluid shifts and limited intake. Increasing the frequency of feedings helps ensure adequate caloric intake and promotes gradual weight gain, supporting healthy growth and hydration.
C. Do nothing because this is a normal occurrence: Although some weight loss is normal, the nurse should take action to support feeding and monitor ongoing weight trends rather than ignoring the loss entirely.
D. Try feeding the infant a different type of formula: Changing formula is not indicated unless the infant has feeding intolerance or a medical reason. The initial intervention should focus on optimizing feeding frequency and technique rather than switching formula.
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