A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.
Which of the following actions should the nurse take
Diagnostic results
Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL
Platelet count 50,000 mm
WBC count 4,000 mm3
The Correct Answer is A
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A respiratory rate of 55 breaths per minute is within the normal range for a full-term newborn, which is generally between 30 and 60 breaths per minute.
B. A heart rate of 72 beats per minute is significantly lower than the normal range for a newborn. Normal heart rates for newborns typically range from 120 to 160 beats per minute. A heart rate this low could indicate bradycardia, which requires immediate assessment and intervention.
C. A temperature 36.5° C (97.7° F) is slightly below the normal range for newborns, which is typically between 36.6°C to 37.2°C (97.9°F to 99.0°F). However, it may not be immediately concerning unless it is part of a pattern or accompanied by other symptoms.
D. A blood pressure reading of 80/50 mm Hg is within the expected range for a full-term newborn, where typical values are approximately 60-80 mm Hg for systolic and 40-50 mm Hg for diastolic.
Correct Answer is B
Explanation
Glyburide is an oral hypoglycemic medication used to control blood glucose levels in individuals with type 2 diabetes. It is also used in the management of gestational diabetes mellitus (GDM) when dietary and lifestyle interventions alone are not sufficient to control blood glucose levels. Glyburide works by stimulating the pancreas to release insulin and also by increasing the sensitivity of peripheral tissues to insulin. It is preferred over insulin injections because it is easier to administer and monitor, and it does not pose a risk of hypoglycemia as long as blood glucose levels are closely monitored. In addition, glyburide does not cross the placenta, which minimizes the risk of fetal hypoglycemia. However, some studies have suggested that glyburide may be associated with an increased risk of neonatal hypoglycemia and macrosomia (large birth weight), so careful monitoring of the mother and fetus is required. Other medications such as levothyroxine, nifedipine, and chlorpromazine are not used in the management of gestational diabetes mellitus.
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