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
Requesting a parent to verify the newborn's name is an important part of the identification process, but it is not the primary method for confirming identity directly on the newborn. Verifying identity relies on objective comparison of identifying markers on both the infant and the parent for accuracy.
Choice B rationale
Checking the newborn's footprint sheet with the medical record is a valid identification method, but typically occurs when the newborn is admitted or for more permanent records. For immediate transport, a direct comparison of armbands between the newborn and parent is the most efficient and readily verifiable method.
Choice C rationale
Asking a parent to state the newborn's date of birth provides information about the newborn. However, this relies on parental recall and is not a direct physical confirmation of the newborn's identity. Physical identifiers like matching band numbers offer a more secure and immediate verification.
Choice D rationale
Comparing numbers on the newborn's band to the parent's band is the most secure and immediate method to confirm identity prior to transport. This ensures that the correct newborn is being given to the designated parent, preventing potential mix-ups and upholding critical safety protocols in maternity care.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) primarily exert their therapeutic effects through the inhibition of cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis. While they possess analgesic and anti-inflammatory properties that can alleviate pain and swelling associated with thrombophlebitis, NSAIDs do not directly prevent the formation of thrombi or address the underlying coagulopathy. Therefore, their administration is not a primary prophylactic measure against thrombophlebitis development.
Choice B rationale
Early and frequent ambulation promotes venous return by stimulating the calf muscle pump, which compresses deep veins and propels blood back towards the heart. This mechanical action counteracts venous stasis, a major component of Virchow's triad for thrombus formation. By maintaining blood flow velocity and preventing pooling in the lower extremities, ambulation significantly reduces the risk of deep vein thrombosis and subsequent thrombophlebitis.
Choice C rationale
Applying warm, moist packs to the lower legs can provide symptomatic relief by promoting vasodilation and improving local circulation, which may reduce pain and inflammation associated with existing thrombophlebitis. However, this intervention does not prevent the initial formation of a thrombus. In fact, vasodilation could theoretically increase blood flow to an area with an active clot, but it does not address the fundamental mechanisms of thrombogenesis, such as stasis or hypercoagulability.
Choice D rationale
Elastic stockings apply external graduated compression to the lower extremities, with the highest pressure at the ankle and gradually decreasing pressure proximally. This external pressure helps to reduce venous distention, increase venous blood flow velocity, and prevent the pooling of blood in the superficial and deep veins. By mitigating venous stasis, a critical factor in the pathogenesis of thrombophlebitis, elastic stockings effectively reduce the risk of thrombus formation.
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