The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?
Bolus of 2 ml/kg glucose 10% IV.
Feed immediately.
Echocardiogram.
Monitor for respiratory distress.
Apply dextrose gel inside the baby’s cheek.
The Correct Answer is E
Choice A rationale
Administering a bolus of 2 ml/kg glucose 10% IV is important for hypoglycemia management, providing rapid glucose delivery. Normal blood glucose level for neonates is 45-90 mg/dL. Severe hypoglycemia requires immediate intervention.
Choice B rationale
Immediate feeding can stabilize blood glucose levels by providing a sustained energy source. Breastfeeding or formula feeding aids in maintaining glucose homeostasis, supporting neonatal metabolic needs and preventing hypoglycemia.
Choice C rationale
An echocardiogram is a non-invasive diagnostic test used to evaluate cardiac structure and function. It is not a priority intervention compared to managing hypoglycemia or respiratory distress, as it does not address immediate neonatal needs.
Choice D rationale
Monitoring for respiratory distress involves observing signs such as tachypnea, grunting, nasal flaring, and retractions. Early identification of respiratory issues is crucial in neonates to prevent complications like respiratory failure.
Choice E rationale
Applying dextrose gel inside the baby’s cheek can quickly raise blood glucose levels in cases of mild hypoglycemia. It is an effective short-term intervention for stabilizing blood glucose while preparing for further treatment.
Choice F rationale
Monitoring temperature every 30 minutes helps detect hypothermia or hyperthermia. Normal neonatal temperature is 36.5-37.5°C (97.7-99.5°F). Maintaining thermal stability is vital to prevent metabolic complications in newborns.
Choice G rationale
Contacting respiratory therapy for arterial blood gas (ABG) and oxygen therapy ensures proper oxygenation and ventilation. ABGs provide critical information on acid-base status, and oxygen therapy supports adequate tissue oxygenation.
Choice H rationale
Keeping the neonate in a warmer with bilirubin lights (phototherapy) treats hyperbilirubinemia by converting bilirubin into a water-soluble form for excretion. Normal bilirubin levels are <12 mg/dL in term neonates. It is not an immediate priority.
Choice I rationale
Transferring to a neonatal intensive care unit (NICU) provides specialized care, including advanced monitoring and interventions for critically ill neonates. NICUs have resources for managing complex medical conditions and ensuring optimal outcomes.
Choice J rationale
Measuring blood glucose levels is essential for assessing neonatal glucose status, especially in high-risk infants. Normal blood glucose levels for neonates are 45-90 mg/dL. Identifying hypoglycemia is critical for prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.
Choice B rationale
Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.
Choice C rationale
Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.
Choice D rationale
Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.
Correct Answer is D
Explanation
Choice A rationale
Obtaining a blood sample for complete blood count is crucial but secondary. The client’s low blood pressure and high heart rate indicate possible hypovolemia requiring immediate intervention to restore blood pressure and perfusion.
Choice B rationale
Infusing normal saline helps restore blood volume. However, it won't address supine hypotension syndrome, caused by uterine compression of the inferior vena cava, which necessitates repositioning the client first to improve hemodynamic stability.
Choice C rationale
Palpating the abdomen for contractions is important in assessing labor progress. Yet, it doesn't address the immediate hemodynamic instability caused by supine hypotension, which needs immediate correction to avoid fetal compromise.
Choice D rationale
Tilting the backboard laterally displaces the uterus off the inferior vena cava, alleviating supine hypotension syndrome. This improves maternal blood pressure and fetal perfusion, addressing the immediate hemodynamic instability effectively.
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