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
Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.
Choice B rationale
Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.
Choice C rationale
Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.
Choice D rationale
Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is Choice A, Choice C, Choice D, Choice E.
Choice A rationale
Genetic counseling is recommended for couples concerned about birth defects to identify any potential genetic abnormalities or risks for inherited conditions.
Choice B rationale
Couples excited about having children do not necessarily require genetic counseling unless there are known risk factors or concerns about genetic conditions.
Choice C rationale
Loss of an embryo following an in-vitro fertilization procedure may indicate underlying genetic issues, warranting further evaluation through genetic counseling.
Choice D rationale
Huntington’s disease is an autosomal dominant disorder; individuals with a family history should seek genetic counseling to assess their risk of inheritance and possible transmission.
Choice E rationale
In-vitro fertilization with donated sperm may involve genetic screening and counseling to ensure the donor's genetic profile is compatible and free of heritable conditions.
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