A nurse is caring for a newborn who is 4 hours old in the Neonatal Intensive Care Unit (NICU).
Exhibits
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 []
• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Terbutaline, a medication used to suppress preterm labor, can cause heart palpitations as an adverse effect. This is due to its action as a beta-adrenergic agonist, which can increase heart rate.
Choice B rationale
Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. Terbutaline is more likely to cause tachycardia, or a fast heart rate.
Choice C rationale
Hot flashes are not a common adverse effect of terbutaline. They are more commonly associated with hormonal changes, such as those that occur during menopause.
Choice D rationale
Shortness of breath is not a typical adverse effect of terbutaline. However, if it occurs, it could indicate a serious condition like pulmonary edema and should be reported immediately.
Correct Answer is A
Explanation
Choice A rationale
Maternal cytomegalovirus (CMV) infection is a serious health concern as it is associated with severe birth defects like sensori-neural hearing loss, impairment of cognitive development, and cerebral palsy. It is acquired by contact with body fluids and by vertical transmission from mother to fetus. Transmission can occur via the saliva and urine of the newborn, which is why this is the correct answer.
Choice B rationale
CMV does not require airborne precautions. It is not an airborne disease; it is spread through close, direct contact with a person infected with the virus.
Choice C rationale
CMV does not cause visible lesions on the mother’s genitalia. This is a characteristic of other sexually transmitted infections, not CMV2.
Choice D rationale
Mothers do not receive prophylactic treatment with acyclovir prior to delivery to prevent CMV2. Acyclovir is an antiviral medication used to treat herpes simplex virus infections, not CMV2.
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