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
A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.
Choice B rationale
A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.
Choice C rationale
A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.
Choice D rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.
Correct Answer is C
Explanation
Choice A rationale
Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.
Choice B rationale
Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.
Choice C rationale
Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.
Choice D rationale
Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.
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