A nurse is caring for a newborn who has a blood glucose level of 40 mg/dL. Which of the following actions should the nurse take?

Encourage the mother to breastfeed the newborn.

Gavage feed 60 mL (2 oz) of glucose water.

Administer 10 mL of D5W via IV.

Recheck the glucose level in 2 hr.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Breastfeeding is the recommended first line of action for a newborn with a blood glucose level of 40 mg/dL, which is on the lower end of the normal range (normal range: 40-60 mg/dL for a newborn). Breast milk provides a natural source of glucose and other nutrients essential for the newborn's growth and development. It also facilitates bonding and has immunological benefits. Early initiation of breastfeeding helps to stabilize the blood glucose levels naturally.

Choice B reason:

Gavage feeding 60 mL of glucose water is not the first choice for managing borderline low blood glucose levels in a newborn. This method is typically reserved for infants who cannot feed orally due to medical conditions or prematurity. It is an invasive procedure and can be stressful for the newborn.

Choice C reason:

Administering 10 mL of D5W (5% dextrose in water) via IV is a treatment for hypoglycemia (low blood glucose levels), not for borderline low levels like 40 mg/dL. This intervention is usually considered when blood glucose levels are significantly lower than the normal range and the infant is symptomatic or unable to tolerate oral feedings.

Choice D reason:

Rechecking the glucose level in 2 hours is a passive approach and may not be appropriate for a newborn with a blood glucose level of 40 mg/dL. Immediate action, such as feeding, is preferred to prevent potential hypoglycemia and its associated risks.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.

Choice B rationale:

A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.

Choice C rationale:

Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.

Choice D rationale:

Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.

Choice E rationale:

Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.

A. Peanut butter sandwich on wheat bread. B. A sliced apple and red grapes. C. A chocolate chip cookie with a glass of skim milk. D. A scrambled egg with cheddar cheese.

Correct Answer is B

Explanation

A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.

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A nurse is caring for a newborn who has a blood glucose level of 40 mg/dL. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

Correct Answer is B

Explanation

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