A nurse is caring for a newborn whose mother has gestational diabetes. The newborn has a blood glucose level of 30 mg/dL and is asymptomatic. Which of the following actions should the nurse take?

Check urine for ketones.

Administer glucagon

Encourage an additional feeding.

Recheck blood glucose in 4 hr.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- Checking urine for ketones is not necessary if the newborn's blood glucose level is low but stable and the baby is asymptomatic.
B)   Incorrect- Administering glucagon is not indicated for an asymptomatic newborn with a low but stable blood glucose level.
C)   Correct - Encouraging additional feeding is appropriate for an asymptomatic newborn with a low blood glucose level. Regular feeding can help increase blood glucose levels.
D)   Incorrect- Waiting 4 hours to recheck blood glucose might not be appropriate if the baby's blood glucose is currently low. Addressing the low blood glucose level is more immediate.

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Correct Answer is A

Explanation

A) Correct- Feeling the baby's swallowing during breastfeeding indicates that the baby is effectively transferring milk from the breast. It suggests that the baby is latched on correctly and is receiving milk.
B) Incorrect- Moderate tenderness during breastfeeding is common initially, but it should not be persistent or severe.
C) Incorrect- While bowel movements are important, having at least one bowel movement every day is not necessarily an indicator of effective breastfeeding.
D) Incorrect- While wet diapers are important to ensure adequate hydration, having at least six wet diapers every day is not the primary sign of effective breastfeeding.

A. Apply a water-based ointment to the newborn's skin every 4 to 6 hr. B. Give the newborn 30 mL of distilled water after each feeding C. Reposition the newborn every 2 to 3 hr. D. Monitor the newborn's blood glucose level every 2 hr

Correct Answer is C

Explanation

A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.

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A nurse is caring for a newborn whose mother has gestational diabetes. The newborn has a blood glucose level of 30 mg/dL and is asymptomatic. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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