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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
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