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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
Correct Answer is C
Explanation
A) Incorrect- Nifedipine is a calcium channel blocker used for conditions like high blood pressure, not for controlling postpartum bleeding.
B) Incorrect- Terbutaline is a bronchodilator and is not typically used for postpartum bleeding.
C) Correct - Oxytocin is a uterotonic medication often used to control excessive bleeding after childbirth. It helps the uterus contract and reduces the risk of postpartum hemorrhage.
D) Incorrect- Betamethasone is a corticosteroid used to enhance fetal lung maturity when given to pregnant clients at risk of preterm birth
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