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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.

Choice B rationale:

This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.

Choice C rationale:

Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.

Choice D rationale:

Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.

A. Vitamin E. B. Vitamin D. C. Fiber. D. Calcium. E. None F. None

Correct Answer is C

Explanation

A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?

Correct Answer is C

Explanation

A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicates an understanding of the teaching?

A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?