A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Select the 5 actions the nurse should take next.
Encourage skin-to-skin contact.
Recheck the newborn's glucose level.
Recheck the newborn's temperature.
Reinforce instruction to the client to breastfeed hourly.
Ensure the newborn is tightly swaddled.
Maintain intravenous catheter for glucose administration.
Schedule lactation consult.
Monitor for signs of dehydration.
Provide supplemental oxygen if needed.
Correct Answer : A,C,D,G
Choice A rationale: Skin-to-skin contact promotes thermoregulation, stabilizes heart rate and respiratory rate, and enhances glucose homeostasis through reduced stress hormone release. It also facilitates breastfeeding by stimulating maternal oxytocin and infant rooting reflexes. In hypoglycemic newborns, skin-to-skin reduces energy expenditure and supports metabolic recovery. This intervention is evidence-based and essential for physiologic stabilization and bonding, especially in infants with feeding difficulties or temperature instability.
Choice B rationale: Rechecking glucose levels is critical to confirm sustained euglycemia and detect rebound hypoglycemia. Neonatal glucose regulation is dynamic, especially in large-for-gestational-age infants. After initial correction, glucose may drop again due to persistent hyperinsulinemia. Monitoring ensures timely intervention and prevents neurologic sequelae. The normal range for neonatal blood glucose is greater than 40 to 45 mg/dL. Serial checks guide feeding frequency and determine need for escalation of care.
Choice C rationale: Temperature monitoring is essential because hypothermia increases glucose utilization and exacerbates hypoglycemia. Newborns have immature thermoregulatory mechanisms and rely on external warmth and brown fat metabolism. A stable temperature of 36.5° C (97.7° F) is ideal. Rechecking ensures that swaddling and skin-to-skin are effective and that no environmental factors are compromising thermal stability. Temperature instability may signal underlying metabolic or infectious processes requiring further evaluation.
Choice D rationale: Reinforcing hourly breastfeeding supports frequent glucose intake and prevents hypoglycemia recurrence. Early and regular feeding is the cornerstone of neonatal glucose management. Hourly feeding ensures adequate caloric delivery, stimulates gastrointestinal motility, and promotes bilirubin excretion. It also helps establish maternal milk supply and improves latch technique through repetition. This action is especially important in infants with initial feeding difficulties or borderline glucose levels.
Choice E rationale: Tightly swaddling provides warmth and comfort but is not a primary intervention once temperature is stable. While swaddling supports thermoregulation and reduces energy expenditure, it does not directly address glucose regulation or feeding. In this case, the newborn’s temperature has normalized, and swaddling has already been implemented. Therefore, it is not a next-step priority but rather a maintenance measure.
Choice F rationale: Maintaining an IV catheter is unnecessary unless glucose levels remain critically low or feeding fails. The newborn’s glucose improved to 50 mg/dL after breastfeeding, indicating effective oral management. IV glucose is reserved for symptomatic hypoglycemia or levels below 25 mg/dL. In this stable scenario, invasive therapy is not warranted and may introduce infection risk or parental anxiety. Thus, it is not an appropriate next action.
Choice G rationale: Scheduling a lactation consult addresses the initial difficulty with latching and supports long-term feeding success. Lactation specialists provide hands-on guidance, assess anatomical barriers, and educate on positioning and milk transfer. Early intervention improves breastfeeding outcomes and reduces risk of hypoglycemia, dehydration, and jaundice. This consult is especially important for large infants with high metabolic demands and mothers needing support.
Choice H rationale: Monitoring for dehydration is important but not immediately indicated unless signs such as poor skin turgor, dry mucosa, or decreased urine output appear. The newborn has breastfed and is sleeping quietly, suggesting adequate hydration. While vigilance is necessary, it is not a top-five priority at this moment. Dehydration monitoring becomes more relevant if feeding remains poor or output declines.
Choice I rationale: Supplemental oxygen is not indicated in a newborn with normal respiratory rate, heart rate, and oxygen saturation. The newborn is alert, crying, and has no retractions or cyanosis. Oxygen therapy is reserved for hypoxemia or respiratory distress. Unnecessary oxygen can suppress respiratory drive and interfere with thermoregulation. Therefore, it is not appropriate in this stable clinical context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Neonatal hypoglycemia is typically defined as a blood glucose concentration below 40 mg/dL in the first 4 hours of life, or below 45 mg/dL between 4 and 24 hours. Glucose levels of 40 to 45 mg/dL are generally considered the goal range to prevent neurological injury, not the normal lower limit for up to 72 hours post-birth.
Choice B rationale
If a newborn's blood glucose levels remain persistently below 40 mg/dL after initial management (like feeding) or if they develop symptomatic hypoglycemia, intravenous dextrose will be required. A value persistently below 50 mg/dL is concerning, but the 40 mg/dL threshold is often the critical point for initiating IV glucose when oral methods fail.
Choice C rationale
The umbilical cord provides the fetus with a continuous supply of glucose via the placenta from the mother. Upon umbilical cord clamping, this maternal glucose supply is abruptly interrupted, requiring the newborn's immature metabolic systems to take over glucose homeostasis. This sudden loss of exogenous glucose is a primary factor in transient newborn hypoglycemia.
Choice D rationale
Frequent breastfeeding provides the newborn with a readily available source of lactose, which is metabolized into glucose, thereby promoting the stability of their blood glucose levels. Early and frequent feeding is the primary intervention for transient hypoglycemia in newborns who are able to feed, utilizing the oral route for caloric intake.
Choice E rationale
Transient hypoglycemia is a common and expected physiological adaptation in term newborns during the initial hours after birth. The abrupt cessation of maternal glucose supply necessitates the newborn's activation of gluconeogenesis and glycogenolysis, which may temporarily be insufficient, leading to a mild, self-limiting drop in blood glucose.
Choice F rationale
Skin-to-skin contact immediately after birth is vital as it prevents cold stress. When a newborn is cold, they must expend energy (calories) to produce heat, which consumes glucose, potentially leading to or exacerbating hypoglycemia. Thermoregulation thus indirectly stabilizes blood glucose levels by conserving energy.
Correct Answer is B
Explanation
Choice A rationale
A late preterm newborn (born between 34 0/7 and 36 6/7 weeks of gestation) often exhibits periods of alertness, but they are also commonly noted to have a sleepy, less sustained alert state compared to a full-term neonate. Their neurological immaturity contributes to poor state regulation and a less vigorous overall response.
Choice B rationale
Thermal instability is an expected finding in late preterm newborns because they have less subcutaneous fat (insulation) than term infants, a higher surface area-to-volume ratio, and immature hypothalamic temperature regulation. This increased vulnerability necessitates careful monitoring and environmental thermoregulation (normal axillary temperature: 36.5°C to 37.3°C).
Choice C rationale
Late preterm newborns are at an increased risk of hypoglycemia (serum glucose ≤ 40 mg/dL) due to inadequate glycogen stores, increased metabolic demands, and immature gluconeogenesis pathways. Hyperglycemia (serum glucose ≥ 125 mg/dL) is not typically expected unless the infant is under high stress or receiving high glucose infusions.
Choice D rationale
Leathery or cracked, dry skin is characteristic of a post-term newborn (born after 42 weeks) due to prolonged exposure to amniotic fluid and desiccation. Late preterm newborns have relatively thin, smooth skin with visible blood vessels because the subcutaneous fat layer is not yet fully developed.
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