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 []
Explanation
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.
Correct Answer is D
Explanation
A. Early decelerations are usually benign and are associated with head compression during contractions.
B. Accelerations are increases in the fetal heart rate above the baseline. They are typically reassuring and indicate fetal well-being.
C. Late decelerations are concerning patterns in fetal heart rate monitoring. They can indicate poor oxygenation of the fetus and may be associated with conditions such as maternal hypotension, placental insufficiency, or other factors compromising blood flow to the fetus.
D. Variable decelerations are abrupt decreases in fetal heart rate that vary in timing, duration, and depth. They are often associated with umbilical cord compression, such as when the cord is being compressed or squeezed during contractions.
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