A nurse is caring for a neonate in the neonatal unit.
Which of the following actions should the nurse take first?
Administer a bolus of intravenous glucose.
Reassess the neonate’s blood glucose level in 30 minutes.
Initiate feeding with formula or breast milk.
Place the neonate under a radiant warmer.
The Correct Answer is A
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse should administer a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Microcephaly is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice B rationale
Polydactyly is a congenital condition involving extra fingers or toes and is not associated with an increased risk of unconjugated bilirubin and jaundice.
Choice C rationale
Caput succedaneum is a condition involving swelling of the scalp in a newborn and is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice D rationale
Cephalohematoma is a collection of blood between a baby’s scalp and the skull bone. It is associated with an increased risk of unconjugated bilirubin and jaundice due to the breakdown of red blood cells in the hematoma. .
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.
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