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 C
Explanation
Choice A rationale
Hyperglycemia in gestational diabetes typically leads to increased urination, or polyuria, not decreased urination. Elevated blood glucose levels overwhelm the renal tubules' reabsorption capacity, leading to glucose spilling into the urine, which then draws water osmotically, increasing urine output.
Choice B rationale
Shallow respirations are not a direct manifestation of hyperglycemia in this context. While severe diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, can lead to Kussmaul respirations (deep, rapid breathing) due to metabolic acidosis, hyperglycemia alone typically does not cause shallow respirations.
Choice C rationale
Thirst, or polydipsia, is a classic manifestation of hyperglycemia. High blood glucose levels increase the osmolality of the blood, stimulating osmoreceptors in the hypothalamus, which then trigger the sensation of thirst as the body attempts to dilute the excess glucose and restore fluid balance.
Choice D rationale
While hunger (polyphagia) is a common symptom in uncontrolled type 1 diabetes due to cellular inability to utilize glucose, in gestational diabetes with hyperglycemia, hunger is not a predominant or consistent symptom. The body typically has sufficient insulin, but there is insulin resistance or insufficient production.
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Douching is generally not recommended as it can disrupt the natural vaginal flora, altering the pH balance and potentially increasing the risk of vaginal infections, including bacterial vaginosis or yeast infections. It does not prevent urinary tract infections and can, in fact, push bacteria further up the urethra, exacerbating the problem.
Choice B rationale
Eliminating yogurt products from the diet is counterproductive. Yogurt, especially those containing live and active cultures like Lactobacillus, can help maintain a healthy balance of bacteria in the genitourinary tract. These beneficial bacteria can help prevent the overgrowth of pathogenic bacteria that contribute to urinary tract infections.
Choice C rationale
Avoiding urinating at bedtime is not advisable. Holding urine for extended periods allows bacteria within the bladder to multiply, increasing the risk of infection. Complete bladder emptying, particularly before and after sexual activity and at regular intervals, is crucial for flushing out bacteria and preventing urinary stasis.
Choice D rationale
Wearing cotton-crotch underwear promotes airflow and reduces moisture retention in the perineal area. Cotton is a breathable fabric that helps prevent a warm, moist environment, which is conducive to bacterial growth. This reduces the risk of bacterial proliferation and subsequent urinary tract infections, promoting genitourinary health.
Choice E rationale
Refraining from taking bubble baths is recommended because the chemicals and dyes in bubble bath solutions can irritate the urethra and vaginal opening. This irritation can create an environment that is more susceptible to bacterial adherence and proliferation, thus increasing the risk of developing a urinary tract infection.
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