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 D
Explanation
Choice D rationale
The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.
Choice A rationale
A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
Choice B rationale
A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.
Choice C rationale
A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.
Correct Answer is C
Explanation
Choice A rationale
Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.
Choice B rationale
Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.
Choice C rationale
Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.
Choice D rationale
Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.
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