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:
The normal WBC count during pregnancy can vary, but a count of 11,000/mm³ is within an acceptable range. During pregnancy, the WBC count can be slightly elevated due to physiological changes in the body to support the growing fetus.
Choice B rationale:
The normal hemoglobin level during pregnancy is generally around 11 to 12.5 g/dL. Therefore, a hemoglobin level of 11.2 g/dL falls within the normal range, and the nurse does not need to report this finding.
Choice C rationale:
The normal hematocrit (Hct) during pregnancy can vary, but a level of 34% is within the acceptable range. Hct levels can be lower during pregnancy due to increased plasma volume, leading to a mild physiological anemia of pregnancy.
Choice D rationale:
The normal platelet count during pregnancy is typically around 150,000 to 400,000/mm³. With a platelet count of 140,000/mm³, this is slightly below the lower end of the normal range. Thrombocytopenia during pregnancy can increase the risk of bleeding, both during childbirth and postpartum, so the nurse should report this finding to the provider for further evaluation and management.
Correct Answer is D
Explanation
Choice A rationale:
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
Choice B rationale:
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
Choice C rationale:
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
Choice D rationale:
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
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