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
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Normal neonatal glucose: >45 mg/dL (ideally 50–110 mg/dL).
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A level of 40 is low → risk for hypoglycemia complications (seizures, brain injury).
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Focusing primarily on her own needs is characteristic of the taking-in phase, where the mother is more self-focused and recovering from the birth process.
Choice B rationale
Being very excited and talkative about the birth experience is also a trait of the taking-in phase, not the taking-hold phase.
Choice C rationale
Interest in learning about infant care indicates the taking-hold phase, where the mother becomes more focused on the baby's needs and her new role as a caregiver.
Choice D rationale
Relying on nursing staff for assistance is common in the taking-in phase, where the mother depends more on others for care.
Correct Answer is C
Explanation
Choice A rationale
Oral contraceptive pills, while effective when taken correctly, rely on user compliance and are not the most reliable if doses are missed.
Choice B rationale
Diaphragms with spermicide are less effective than IUDs and require proper placement before intercourse, making them more prone to user error.
Choice C rationale
Intrauterine devices (IUDs) are long-term, highly effective contraceptive methods with low failure rates, and they do not depend on daily user compliance.
Choice D rationale
Male condoms are effective but have a higher failure rate compared to IUDs due to potential breakage or improper use.
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