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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pruritus is not a common manifestation of hyperemesis gravidarum; it might be associated with liver conditions or other issues.
B. Decreased blood pressure can be an expected manifestation in hyperemesis gravidarum due to dehydration and possible hypovolemia.
C. Hemoglobin of 18 g/dL is higher than normal; hyperemesis gravidarum often leads to decreased hemoglobin due to malnutrition and dehydration.
D. A WBC count of 15,000/mm³ is slightly elevated but not specific for hyperemesis gravidarum; it might be indicative of an infection or inflammation, but it is not a defining characteristic of the condition.
Correct Answer is D
Explanation
A. Increasing the frequency of feedings from the affected nipple can worsen soreness. It’s important to address the underlying cause of soreness, which may involve evaluating latch technique or positioning rather than increasing feeding frequency.
B. Vitamin E oil is not recommended for sore nipples as it can cause irritation. Proper care involves managing latch and positioning, and sometimes using a lanolin cream rather than oils or other substances.
C. Washing the nipple with soap and water before each feeding can remove natural oils and lead to further irritation. The nipple should be gently cleaned with water, if necessary, and kept clean without over-washing.
D. Exposing the affected nipple to the air between feedings helps with healing and reduces moisture, which can exacerbate soreness. Allowing the nipple to air-dry can promote healing and reduce discomfort.
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