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.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.
Correct Answer is B
Explanation
A. Asymptomatic palpitations are generally not a concern during pregnancy. They can be a common and benign experience due to increased blood volume and changes in heart function.
B. Abdominal cramping at 26 weeks of gestation may indicate preterm labor or other complications and should be reported to the provider. Persistent or severe cramping can be a sign of potential issues requiring medical evaluation.
C. Bleeding gums are common due to increased blood flow and hormonal changes in pregnancy. This symptom is usually not serious but should still be monitored.
D. White vaginal discharge is normal during pregnancy and often increases as pregnancy progresses. It is usually not a sign of a problem unless accompanied by other symptoms.
Here’s a detailed answer for each of the s using the specified format:
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