A nurse is caring for a newborn whose blood glucose level is 40. Which of the following interventions has priority in the nurse's plan of care?
Evaluate glucose levels again in 4 hours.
Assess for hypothermia.
Notify MD on call.
Evaluate blood serum glucose.
The Correct Answer is C
Choice A rationale
While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.
Choice B rationale
Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.
Choice C rationale
Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.
Choice D rationale
Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Apgar score assesses the newborn's health at 1 and 5 minutes post-delivery. A score of 8 at 1 minute and 10 at 5 minutes indicates good initial adaptation to extrauterine life.
Choice B rationale
Suctioning the mouth with a bulb syringe helps clear the airway of any meconium, which can be crucial to prevent respiratory complications.
Choice C rationale
Absence of visible meconium in the airway reduces the risk of meconium aspiration syndrome, a serious condition affecting the newborn's respiratory system.
Choice D rationale
Antibiotics are not routinely started after birth for all infants; they are used if there is a high risk or evidence of infection.
Correct Answer is D
Explanation
Choice A rationale
It is important to encourage breastfeeding rather than offering formula, especially if the mother wishes to breastfeed.
Choice B rationale
Pumping is not necessary at this time as the baby is just 4 hours old and establishing feeding patterns.
Choice C rationale
Consulting the pediatrician is not immediately necessary for this situation.
Choice D rationale
Teaching the mother about newborn sleep and hunger patterns is appropriate, as newborns often have irregular feeding schedules in the first few days. .
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