A nurse is assisting in the care of a newborn in the postpartum unit.
Complete the following sentence by using the lists of options.
The nurse should first address the newborn's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
? Rationale for Correct Answers
Glucose level is the priority because the newborn’s blood glucose is 35 mg/dL, which is below the normal threshold of 40–45 mg/dL. Neonatal hypoglycemia can lead to seizures, apnea, and brain injury if untreated. Immediate intervention is critical to prevent neurologic damage.
Feeding difficulties are the next concern because they contribute to poor caloric intake and perpetuate hypoglycemia. The newborn exhibits poor latch, uncoordinated suck, and loose stools—hallmarks of neonatal abstinence syndrome (NAS), which impair feeding and weight gain.
❌ Rationale for Incorrect Response 1 Options
Respiratory rate (65/min) is mildly elevated but within the upper limit of normal for newborns (30–60/min). No signs of respiratory distress (e.g., nasal flaring, retractions, grunting) are present, making this a lower priority.
Heart rate (165/min) is within the normal neonatal range (120–160/min). Mild tachycardia can be attributed to irritability or crying and is not immediately life-threatening.
Temperature (37.5°C) is within the normal range for newborns (36.5–37.5°C). There is no evidence of fever or hypothermia requiring urgent intervention.
❌ Rationale for Incorrect Response 2 Options
Skin findings such as mottling are nonspecific and often seen in NAS or immature autonomic regulation. They are not immediately dangerous.
Cry characteristics like high-pitched crying are typical of NAS but are not life-threatening and do not require urgent intervention.
Tremors are a common NAS symptom but are not acutely harmful unless associated with seizures, which are not reported here.
? Take-Home Points
- Neonatal hypoglycemia (<40 mg/dL) is a medical emergency requiring prompt correction to prevent neurologic injury.
- Feeding difficulties in NAS exacerbate hypoglycemia and must be addressed to ensure adequate caloric intake.
- NAS presents with autonomic, gastrointestinal, and neurologic symptoms; diagnosis is clinical and supported by maternal and neonatal drug screens.
- NAS must be differentiated from neonatal sepsis, hypoxic-ischemic encephalopathy, and metabolic disorders, which may present similarly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying vitamin E oil to nipples after each feeding is not routinely recommended. While vitamin E possesses antioxidant properties, its efficacy in preventing or treating nipple soreness during breastfeeding is not scientifically established and could potentially interfere with the natural healing process or introduce allergens to the infant. Proper latch and positioning are the primary interventions for nipple discomfort.
Choice B rationale
Nursing for only 5 to 10 minutes on each breast is typically insufficient for adequate milk transfer and foremilk/hindmilk balance. Infants need to feed until they spontaneously unlatch, ensuring they receive the calorie-dense hindmilk crucial for growth and satiety, which is released later in a feeding session due to increasing fat content.
Choice C rationale
Ensuring only the nipple is in the baby's mouth is incorrect and can lead to ineffective milk transfer and nipple soreness. For an effective latch, the baby needs to take in a large portion of the areola, not just the nipple, allowing for compression of the milk sinuses beneath the areola to effectively express milk.
Choice D rationale
Positioning the baby on a pillow at breast level promotes proper alignment and a comfortable latch. This ergonomic approach reduces strain on the mother's back and arms, allowing the baby to come to the breast at the correct height, facilitating a deep and effective latch where the baby can open wide and take in sufficient breast tissue.
Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A rationale: Transient hypoglycemia is a common physiologic occurrence in term newborns during the first few hours after birth due to the abrupt cessation of maternal glucose supply. The newborn must transition to endogenous glucose production through glycogenolysis and gluconeogenesis. This transitional dip typically resolves with feeding and thermoregulation, making this statement scientifically accurate and reflective of normal neonatal adaptation.
Choice B rationale: Skin-to-skin contact enhances thermoregulation by reducing heat loss through conduction and evaporation. Maintaining a stable body temperature reduces metabolic demands and conserves glucose stores. Additionally, skin-to-skin contact promotes early breastfeeding, which provides exogenous glucose. These combined effects help stabilize neonatal blood glucose levels, making this an evidence-based intervention for hypoglycemia prevention and management.
Choice C rationale: Clamping the umbilical cord terminates the placental transfer of maternal glucose, which is the fetus’s primary energy source in utero. After birth, the newborn must rely on hepatic glycogen stores and initiate gluconeogenesis to maintain glucose homeostasis. This sudden metabolic shift can lead to transient hypoglycemia, especially in infants with increased glucose demands or limited glycogen reserves.
Choice D rationale: Persistent hypoglycemia, particularly glucose levels consistently below 50 mg/dL despite adequate feeding, may necessitate intravenous glucose administration to prevent neurologic injury. IV dextrose provides immediate correction of hypoglycemia when oral intake is insufficient or symptoms are severe. This intervention is especially critical in symptomatic infants or those at high risk, such as macrosomic newborns or infants of diabetic mothers.
Choice E rationale: The lower limit of normal blood glucose in neonates is generally considered to be 40 mg/dL in the first 4 hours and 45 mg/dL after that. However, stating that 40 to 45 mg/dL is the normal lower limit for up to 72 hours is imprecise. Glucose thresholds vary slightly by institution and age in hours, and levels should ideally rise above 50 mg/dL with feeding. Therefore, this statement lacks full accuracy.
Choice F rationale: Frequent breastfeeding provides a consistent source of glucose and stimulates endogenous insulin regulation. Early and effective feeding is the primary intervention for asymptomatic hypoglycemia in term infants. Breast milk contains lactose, which is metabolized into glucose and galactose, supporting energy needs. Therefore, this statement correctly reflects the role of frequent feeding in stabilizing neonatal glucose levels.
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