A nurse is assisting with the care of a newborn who is 4 hr old.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Potential Condition: Hypoglycemia
- Rationale: The jitteriness and weak cry can be signs of hypoglycemia, which is common in newborns, especially those with higher birth weights or whose mothers have diabetes or, in this case, a history of substance use during pregnancy.
Actions to Take:
1. Reinforce with the parent to feed the newborn: Feeding can help to stabilize the newborn's blood sugar levels.
2. Anticipate a prescription to obtain a capillary blood sample: This will confirm the diagnosis by measuring the newborn's blood glucose levels.
Parameters to Monitor:
1. Temperature: To ensure the newborn maintains a normal body temperature, as hypothermia can be associated with hypoglycemia.
2. Respiratory status: To monitor for any changes that could indicate worsening of the condition or other complications.
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Related Questions
Correct Answer is C
Explanation
A. Beginning each feeding with the same breast as the previous feeding is not necessary for effective breastfeeding. It is recommended to allow the newborn to fully drain the first breast before switching to the other side to ensure they receive both foremilk and hindmilk.
B. Newborns do not need additional water. Breast milk or formula provides all the hydration and nutrients a newborn requires, and offering water can interfere with the newborn’s intake of essential nutrients and calories.
C. Allowing the newborn to empty the first breast before switching sides ensures they receive the complete range of milk, including both foremilk and hindmilk, which supports optimal growth and satisfaction.
D. Providing a formula supplement is not typically necessary unless specifically indicated for medical reasons. Exclusive breastfeeding is recommended for the first six months of life, and formula should not be introduced without cause.
Correct Answer is B
Explanation
A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.
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