A nurse is caring for a 4-hour-old newborn in the neonatal unit. The newborn exhibits symptoms of distress, including jitteriness and rapid respirations.
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The Correct Answer is []
Condition: Hypoglycemia
Actions: Feed the newborn immediately with breastmilk or formula. Obtain a capillary blood glucose reading.
Parameters: Blood glucose levels. Respiratory effort.
Rationale for correct condition: The newborn's blood glucose level is significantly low at 30 mg/dL. Symptoms like jitteriness, rapid respirations, and mottling are indicative of hypoglycemia. The newborn has not been fed since birth, which can cause low blood sugar. The temperature is slightly low, another sign of hypoglycemia. Immediate feeding can help stabilize blood glucose levels.
Rationale for actions: Feeding the newborn will raise the blood glucose level quickly. A capillary blood glucose reading is crucial to confirm the diagnosis and monitor effectiveness of the treatment. IV glucose might be necessary if the newborn cannot feed or if the blood glucose does not stabilize. Phototherapy and a radiant warmer are not required unless other conditions are present.
Rationale for parameters: Monitoring blood glucose levels ensures the newborn's hypoglycemia is addressed effectively. Respiratory effort must be monitored to ensure that the rapid respirations normalize with the correction of blood glucose levels. Serum bilirubin levels and skin integrity are not directly related to hypoglycemia.
Rationale for incorrect conditions: Congenital heart defect would likely present with more severe respiratory distress or cyanosis, not just acrocyanosis and jitteriness. Neonatal sepsis would present with signs of infection like fever or lethargy, neither of which is observed here. Neonatal abstinence syndrome would include symptoms such as irritability, high-pitched crying, and feeding difficulties, not specifically observed in this newborn.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Collecting a dietary history is important but not directly relevant to providing information about contraception options.
Choice B rationale
Assessing the client's socioeconomic status may be useful for understanding their circumstances but is not a direct method of discussing contraception.
Choice C rationale
Performing unbiased teaching is essential. The nurse should provide comprehensive information about all available methods of contraception in an unbiased manner, enabling the client to make an informed decision.
Choice D rationale
Selecting the best method of contraception for the client undermines the client's autonomy. The nurse's role is to educate and support the client in making their own informed choice.
Correct Answer is A
Explanation
Choice A rationale
A multiple marker screening is performed during pregnancy to detect neural tube defects and other chromosomal abnormalities. This test includes measurements of specific substances in the mother’s blood and is done between the 15th and 20th weeks of pregnancy.
Choice B rationale
A glucose tolerance test is conducted to screen for gestational diabetes in the mother, not to predict hyperglycemia in the baby. This test typically occurs between 24 and 28 weeks of pregnancy.
Choice C rationale
A Papanicolaou (Pap) test is used to detect precancerous or cancerous cells on the cervix, and it does not identify herpes simplex virus type 1. It is generally performed as part of routine gynecological exams.
Choice D rationale
Group B streptococcus (GBS) screening is performed to detect the presence of GBS bacteria in pregnant women, not sexually transmitted infections (STIs). This test helps prevent neonatal infection and is typically done between 35 and 37 weeks of pregnancy.
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