A nurse is caring for a newborn.
Complete the diagram by specifying:
- The potential condition the newborn is most likely experiencing.
- Two actions the nurse should take to address that condition.
- Two parameters the nurse should monitor to assess the newborn's progress.
The Correct Answer is []
1. Potential Condition:
- Hypoglycemia: The newborn is jittery and has decreased muscle tone, which are common signs of hypoglycemia (low blood sugar), especially in a newborn large for gestational age.
2. Actions to Take:
- Check the newborn's capillary blood glucose level: This is crucial to confirm if hypoglycemia is the issue and to determine the appropriate treatment.
- Place the newborn under a radiant warmer: This action helps stabilize the newborn’s body temperature, which is important as hypoglycemia can sometimes be associated with temperature instability.
3. Parameters to Monitor:
- Temperature: Monitoring the temperature is important to ensure the newborn maintains normal body temperature and to identify any possible hypothermia.
- Seizure activity: Jitteriness can sometimes progress to seizures if hypoglycemia is severe, so monitoring for seizure activity is critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Cullen's sign is a clinical sign characterized by superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is indicative of intra-abdominal bleeding, such as from a ruptured ectopic pregnancy. Blood in the peritoneum can track along fascial planes to the umbilical area, resulting in discoloration and swelling.
Correct Answer is B
Explanation
One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.
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