A nurse is caring for a newborn who is 4 hours old in the maternity unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities, all of which are signs of low blood sugar. The newborn's large birth weight (4,366 g) further increases the risk of hypoglycemia. Immediate feeding is crucial to increase blood sugar levels, and phototherapy can help manage any potential jaundice, which is often associated with hypoglycemia.
Feeding the newborn is essential to provide glucose and stabilize blood sugar levels. Monitoring phototherapy ensures effective treatment of jaundice, which often coexists with hypoglycemia in newborns.
Assessing skin integrity is necessary to prevent complications from jaundice and ensure proper phototherapy response. Monitoring bilirubin levels helps track jaundice severity and the effectiveness of treatment.
Kernicterus, a severe form of jaundice, is less likely because the newborn's symptoms primarily indicate hypoglycemia. Neonatal Abstinence Syndrome, due to maternal drug use, typically involves different symptoms such as irritability, excessive crying, and poor feeding. Congenital Syphilis is ruled out as the mother was treated and tests for syphilis are negative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.
Correct Answer is A
Explanation
Choice A rationale
A single crease in the palm, known as a simian crease, is a common characteristic seen in infants with trisomy 21 (Down syndrome) due to the unique hand structure associated with this condition.
Choice B rationale
A notch in the lip, such as a cleft lip, is not commonly associated with trisomy 21 and is more typically related to other genetic conditions or environmental factors during development.
Choice C rationale
An inversion of the foot, such as clubfoot, is not a specific characteristic of trisomy 21. This condition is more often seen in other congenital anomalies not related to Down syndrome.
Choice D rationale
Extra digits on the hand, or polydactyly, is not commonly associated with trisomy 21 but can be seen in other genetic disorders. Trisomy 21 has more specific physical features like the simian crease.
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