An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action?
Select one:

Prepare for IV dextrose administration.

Provide routine care, per hospital IDM protocol.

Place the infant in a warmed incubator.

Alert the clinician immediately for orders.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Prepare for IV dextrose administration. This is an incorrect answer that indicates an unnecessary and invasive intervention for an IDM with normal blood glucose. IV dextrose administration is indicated for an IDM with severe or persistent hypoglycemia, which is defined as a blood glucose below 40 mg/dL or below 60 mg/dL after two feedings.

Choice B Reason: Provide routine care, per hospital IDM protocol. This is because a blood glucose of 60 is within the normal range for an IDM, which is 40 to 80 mg/dL. An IDM is a newborn whose mother has pre-existing or gestational diabetes, which can aﬀect the fetal and neonatal glucose metabolism and regulation. An IDM may have hypoglycemia (low blood glucose), hyperglycemia (high blood glucose), or other complications such as macrosomia, polycythemia, or congenital anomalies. An IDM requires routine care and monitoring according to the hospital IDM protocol, which may include blood glucose testing, feeding, temperature regulation, and observation for signs of distress.

Choice C Reason: Place the infant in a warmed incubator. This is an incorrect answer that suggests an irrelevant and potentially harmful action for an IDM with normal blood glucose. Placing the infant in a warmed incubator is indicated for an IDM with hypothermia, which is a low body temperature that can impair glucose utilization and increase oxygen consumption. However, placing the infant in a warmed incubator without proper indication can cause hyperthermia, which is a high body temperature that can lead to dehydration, electrolyte imbalance, or brain damage.

Choice D Reason: Alert the clinician immediately for orders. This is an incorrect answer that implies an urgent and unwarranted situation for an IDM with normal blood glucose. Alerting the clinician immediately for orders is indicated for an IDM with signs of distress or complications, such as apnea, cyanosis, seizures, or jaundice.

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Correct Answer is C

Explanation

Choice A Reason: Late decelerations. This is an incorrect answer that refers to a diﬀerent type of fetal heart rate patern that indicates uteroplacental insufficiency, which can reduce blood ﬂow and oxygen delivery to the fetus. Late decelerations are characterized by gradual decreases in fetal heart rate that begin after the peak of uterine contractions and return to baseline after the end of contractions. Amnioinfusion is not eﬀective for late decelerations, as it does not address the underlying cause of uteroplacental insufficiency, which may be due to maternal hypertension, diabetes, preeclampsia, or placental abruption.

Choice B Reason: Moderate decelerations. This is an incorrect answer that refers to a non-existent type of fetal heart rate patern, as there is no such term as moderate decelerations. The term moderate refers to the category of fetal heart rate variability, which is a measure of the ﬂuctuations in fetal heart rate around the baseline. Moderate variability indicates normal fetal oxygenation and well-being, while absent or minimal variability indicates fetal hypoxia or distress.

Choice C Reason: Variable decelerations. This is because variable decelerations are a type of fetal heart rate patern that indicates cord compression, which can reduce blood ﬂow and oxygen delivery to the fetus. Variable decelerations are characterized by abrupt decreases in fetal heart rate that vary in onset, depth, and duration, and do not have a consistent relationship with uterine contractions. Amnioinfusion is a procedure that involves infusing saline or lactated Ringer's solution into the amniotic cavity through a transcervical catheter, which can relieve cord compression by increasing the volume of amniotic ﬂuid and cushioning the cord. Amnioinfusion can improve fetal oxygenation and reduce variable decelerations.

Choice D Reason: Early decelerations. This is an incorrect answer that refers to a diﬀerent type of fetal heart rate patern that indicates head compression, which can stimulate the vagus nerve and slow down the fetal heart rate. Early decelerations are characterized by gradual decreases in fetal heart rate that begin with the onset of uterine contractions and return to baseline with the end of contractions. Early decelerations are benign and do not require intervention, as they reﬂect normal fetal head descent and progress of labor. Amnioinfusion is not indicated for early decelerations, as it does not aﬀect head compression or vagal stimulation.

A. Episodes of hypoglycemia and hyperglycemia. B. Postpartum hemorrhage. C. Cerebrovascular accident (CVA). D. Acute vasospasm.

Correct Answer is A

Explanation

Choice A Reason: Episodes of hypoglycemia and hyperglycemia. This is because episodes of hypoglycemia and hyperglycemia are common complications of diabetes during pregnancy, which can aﬀect both the mother and the fetus. Hypoglycemia is a condition where the blood glucose level drops below the normal range, which can cause symptoms such as sweating, trembling, hunger, confusion, or loss of consciousness. Hyperglycemia is a condition where the blood glucose level rises above the normal range, which can cause symptoms such as thirst, polyuria, fatigue, blurred vision, or ketoacidosis. Diabetes during pregnancy requires careful monitoring and management of blood glucose levels to prevent adverse outcomes such as fetal macrosomia, congenital anomalies, stillbirth, or neonatal hypoglycemia.

Choice B Reason: Postpartum hemorrhage. This is an incorrect answer that refers to a diﬀerent complication that may occur after delivery, not during pregnancy. Postpartum hemorrhage is excessive bleeding from the uterus or genital tract after delivery, which can cause hypovolemic shock, anemia, or death. Postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.

Choice C Reason: Cerebrovascular accident (CVA). This is an incorrect answer that indicates a rare and severe complication that may occur during or after pregnancy, not specifically related to diabetes. CVA is also known as stroke, which is an interruption of blood ﬂow to the brain due to ischemia or hemorrhage, which can cause neurological deficits or death. CVA can be caused by hypertension, preeclampsia-eclampsia, thrombophilia, or vascular malformations.

Choice D Reason: Acute vasospasm. This is an incorrect answer that suggests a diﬀerent condition that may occur during pregnancy, not associated with diabetes. Acute vasospasm is also known as Raynaud's phenomenon, which is a disorder of blood vessels that causes them to narrow and reduce blood ﬂow to the extremities in response to cold or stress, which can cause pain, numbness, or color changes. Acute vasospasm can be triggered by smoking, medications, or autoimmune diseases.

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An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action? Select one:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action?
Select one: