A newborn is diagnosed with hypoglycemia.
Which intervention should the nurse prioritize?
Administering IV insulin.
Encouraging frequent breastfeeding.
Monitoring blood pressure.
Administering a hypertonic saline solution.
The Correct Answer is B
Encouraging frequent breastfeeding.
This is because breastfeeding provides glucose to the newborn baby, which can help prevent or treat hypoglycemia (low blood sugar). Hypoglycemia can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because administering IV insulin would lower the blood sugar level even more, which could be dangerous for the baby.
Choice C is wrong because monitoring blood pressure is not directly related to hypoglycemia.
Blood pressure may be affected by other factors such as stress, infection, or dehydration.
Choice D is wrong because administering a hypertonic saline solution would increase the sodium level in the blood, which could cause dehydration and electrolyte imbalance.
A hypertonic saline solution is not a source of glucose for the baby.
Normal ranges for blood glucose levels in newborns are between 47 to 85 mg/dL. Hypoglycemia is defined as blood glucose below 47 mg/dL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells.It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.
Therefore, it is essential to obtain informed consent from the parent before performing ET.
Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.
Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.
Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.
Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.
Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.
Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.
Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn.The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors.According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.
Correct Answer is C
Explanation
Discontinue the oxytocin (Pitocin) infusion.This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate alate deceleration, which is a sign offetal hypoxia.Oxytocin is a drug that stimulates uterine contractions and can causeuterine hyperstimulation, which reduces blood flow to the placenta and the fetus.By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.
Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused.Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.
Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time.The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.
Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.
Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting
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