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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 Covering the umbilical cord stump with the diaper can create a moist environment, which may increase the risk of bacterial growth and infection.
B. Washing the cord stump with soap and water may disrupt the natural drying process and increase the risk of infection
C. Applying petroleum jelly or any other substance to the umbilical cord stump is not necessary and may increase the risk of infection.

Correct Answer is B

Explanation

53. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, most commonly in the fallopian tube. One of the hallmark symptoms of an ectopic pregnancy is unilateral, cramp-like abdominal pain depending on the location of the pregnancy.
A. Uterine enlargement greater than expected for gestational age is not expected in an ectopic pregnancy because the fertilized egg implants outside the uterus, so there is no uterine enlargement.
C. Severe nausea and vomiting are more commonly associated with conditions such as hyperemesis gravidarum or early pregnancy symptoms but are not specific to ectopic pregnancy.
D. A large amount of vaginal bleeding may occur in some cases of ectopic pregnancy, but it is not a consistent or defining characteristic.

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