A nurse is caring for a neonate in the neonatal intensive care unit (NICU).
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the newborn’s progress.
The Correct Answer is []
Hyperbilirubinemia
- Symptoms: The neonate does show signs of jaundice (yellowish skin), which is a symptom of hyperbilirubinemia. However, the primary concern here is the low blood glucose level (30 mg/dL), which is more immediately life-threatening and needs urgent attention.
- Diagnostic Results: The total serum bilirubin level is 5 mg/dL, which is elevated but not critically high. Hyperbilirubinemia might be a secondary concern, but the immediate symptoms and diagnostic results point more towards hypoglycemia.
Neonatal Abstinence Syndrome (NAS)
- Symptoms: NAS typically occurs in newborns exposed to addictive substances in utero, leading to withdrawal symptoms after birth. Common symptoms include irritability, high-pitched crying, tremors, and feeding difficulties.
- History: There is no mention of maternal substance use or withdrawal symptoms like frequent yawning or irritability. The jitteriness and poor feeding could overlap with NAS, but the history of gestational diabetes and the low blood glucose level make hypoglycemia a more likely diagnosis.
Summary
- Hypoglycemia: The neonate’s symptoms (jitteriness, lethargy, poor feeding) and the critically low blood glucose level (30 mg/dL) strongly indicate hypoglycemia. This condition is common in infants of diabetic mothers and large-for-gestational-age infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.
Choice B rationale
Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.
Choice C rationale
Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.
Choice D rationale
Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.
Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash seen in newborns. It appears as red patches with small white or yellow pustules in the center. It is not characterized by small raised pearly white spots on the nose and chin.
Choice B rationale
Milia spots are small raised pearly white spots that commonly appear on the nose, chin, and cheeks of newborns. They are caused by trapped keratin and are harmless, usually resolving on their own within a few weeks.
Choice C rationale
Mongolian spots are flat, blue-gray patches commonly found on the lower back and buttocks of newborns, especially those with darker skin. They are not raised and do not appear on the nose and chin.
Choice D rationale
Epstein’s pearls are small white or yellow cysts found on the gums or roof of the mouth in newborns. They are not found on the nose and chin. .
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