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 A
Explanation
A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.
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