A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution.

Which of the following interventions should the nurse include in the plan?

Monitor blood glucose levels every hour until stable.

Administer glucagon subcutaneously as prescribed.

Discontinue IV dextrose when blood glucose reaches 60 mg/dL.

Feed breast milk or formula every four hours.

Answer and Explanation

The Correct Answer is A

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed. This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns. Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL. This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL. Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours. This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia. Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand. Breast milk or formula can also be supplemented with IV dextrose if needed.

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Correct Answer is D

Explanation

All of the above.

The nurse should take all of the following actions to prevent increased intracranial pressure (ICP) in a preterm infant who has intraventricular hemorrhage (IVH):

• Elevate the head of the bed to 30 degrees.This helps to reduce venous congestion and improve cerebral blood flow.

• Avoid suctioning unless absolutely necessary.Suctioning can cause hypoxia, bradycardia, and increased ICP.

• Administer analgesics as prescribed.Pain can increase blood pressure and ICP.

Choice A is wrong because elevating the head of the bed alone is not enough to prevent increased ICP.

Choice B is wrong because avoiding suctioning alone is not enough to prevent increased ICP.

Choice C is wrong because administering analgesics alone is not enough to prevent increased ICP.

A. Initiate phototherapy immediately B. Notify the provider to order a serum bilirubin test C. Encourage the parent to feed the newborn more frequently D. Reassure the parent that this is a normal finding

Correct Answer is B

Explanation

Transcutaneous bilirubin measurement is a useful screening tool for neonatal hyperbilirubinemia, but it has some limitations and sources of variability.Therefore, any bilirubin screening result obtained must be confirmed by a diagnostic method before treatment.

Choice A is wrong because initiating phototherapy without confirming the bilirubin level could expose the newborn to unnecessary treatment and potential adverse effects.

Choice C is wrong because increasing hydration by feeding more frequently may not be sufficient to lower the bilirubin level if it is too high or if there are other causes of jaundice.

Choice D is wrong because reassuring the parent that this is a normal finding could delay the diagnosis and treatment of severe neonatal hyperbilirubinemia, which can lead to serious complications such as kernicterus spectrum disorders.

Normal ranges for transcutaneous bilirubin measurement vary depending on the device used, the skin pigmentation, and the postnatal age of the newborn.However, a general guideline is that a measurement of 16 mg/dL at 48 hours of age is above the 95th percentile and warrants further investigation.

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A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preterm infant who has intraventricular hemorrhage (IVH). Which of the following actions should the nurse take to prevent increased intracranial pressure (ICP)?

Correct Answer is D

Explanation

A nurse is reviewing the transcutaneous bilirubin measurement of a newborn who is 48 hours old and has physiologic jaundice. The measurement is 16 mg/dL. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is educating the parents of a newborn who has hypoglycemia about how to feed their baby. The nurse should instruct the parents to do which of the following actions?

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A nurse is reviewing the laboratory results of a newborn who has hypoglycemia. The nurse should identify that a normal blood glucose level for a healthy term newborn is between which of the following ranges?

A nurse is evaluating the effectiveness of phototherapy for a post-term infant who has hyperbilirubinemia due to ABO incompatibility with the mother’s blood type O negative and infant’s blood type B positive. Which of the following findings indicates that phototherapy is effective?

A nurse is educating a parent about how to care for a newborn who has hyperbilirubinemia at home. Which of the following statements by the parent indicates an understanding of the teaching?

The nurse is educating a client about the signs and symptoms of hypoglycemia in a newborn. Which of the following should the nurse include?

A nurse is planning care for a post-term infant who has hypoglycemia and is receiving IV dextrose solution.

Which of the following interventions should the nurse include in the plan?