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A nurse is caring for a newborn.

Exhibits

Complete the diagram by specifying:

  1. The potential condition the newborn is most likely experiencing.
  2. Two actions the nurse should take to address that condition.
  3. Two parameters the nurse should monitor to assess the newborn's progress.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

A fetal heart rate of 158/min is within the normal range for a fetus.

B. Respirations of 16/min are within the normal range for an adult.

C. Headache can be a symptom of pre-eclampsia, but it does not necessarily indicate magnesium toxicity.
D. Decreased urinary output can indicate renal insufficiency or impaired kidney function, which can be a sign of magnesium toxicity.

Correct Answer is D

Explanation

A pink rash appearing on the newborn's trunk while receiving phototherapy may indicate a potential adverse reaction to the treatment, such as a phototoxic reaction or erythema. This finding should be promptly assessed by the nurse as it may indicate skin irritation or sensitivity to the phototherapy.
A. The mother applying lotion to the newborn's skin is generally not contraindicated during phototherapy,

B. Covering the newborn's eyes with a mask is a standard practice during phototherapy to protect the eyes from exposure to the light, and it does not typically require intervention.
C. An increase in the number of newborn's stools is a common side effect of phototherapy and is not typically concerning unless accompanied by other symptoms such as diarrhea or dehydration.

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