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 A
Explanation
A. A respiratory rate of 10/min indicates magnesium sulfate toxicity, which can cause respiratory depression. Close monitoring of respiratory rate is essential to identify and manage potential toxicity.
B. Urine output of 40 mL/hr is not an immediate sign of toxicity but requires monitoring. Decreased urine output can be a sign of complications, but it is not the primary indicator of magnesium sulfate toxicity.
C. Nausea is a common side effect of magnesium sulfate but not necessarily indicative of toxicity. More severe symptoms like respiratory depression are critical for diagnosing toxicity.
D. Facial flushing is a common, mild side effect of magnesium sulfate and not a sign of toxicity. Monitoring for more severe symptoms is essential to assess for toxicity.
Correct Answer is C
Explanation
A. One cup of pasta contains some folate, but it is not the best source for increasing folate intake during pregnancy. Pasta provides carbohydrates but is not as rich in folate compared to leafy greens.
B. One large egg contains a moderate amount of folate but is not the highest source of folate compared to other foods. Eggs provide several nutrients, but for folate, there are better food options.
C. One cup of cooked spinach is a highly recommended food for increasing folate intake. Spinach is rich in folate, which is essential for fetal development, including preventing neural tube defects.
D. Half a cup of orange juice provides a decent amount of folate but is not as high in folate as one cup of cooked spinach. While orange juice can contribute to folate intake, it does not match the folate content of leafy greens like spinach.
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