A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
Obtain a blood glucose level.
Feed the infant glucose water (10%).
Administer oxygen.
Decrease environmental stimuli.
The Correct Answer is A
Choice A rationale
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.
Choice B rationale
Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.
Choice C rationale
No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.
Choice D rationale
Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.
Correct Answer is C
Explanation
Choice A rationale
Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.
Choice B rationale
Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.
Choice C rationale
Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.
Choice D rationale
While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.
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