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 D

Explanation

Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.

Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.

Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.

Choice D Reason:"The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.

A. Taking the newborn to the nursery for the initial assessment. B. Allowing the mother a chance to rest without the baby immediately after delivery. C. Placing the newborn under a radiant warmer to do the initial assessment. D. Placing the newborn on the maternal abdomen and doing the initial assessment.

Correct Answer is D

Explanation

Choice A Reason: Taking the newborn to the nursery for the initial assessment. This is an ineﬀective intervention that disrupts parental atachment by separating the mother and the newborn. It also deprives the newborn of the benefits of skin to skin contact and breastfeeding.

Choice B Reason: Allowing the mother a chance to rest without the baby immediately after delivery. This is an unnecessary intervention that delays parental atachment by postponing the first contact between the mother and the newborn. It also ignores the mother's desire and readiness to hold and feed her baby.

Choice C Reason: Placing the newborn under a radiant warmer to do the initial assessment. This is an outdated intervention that hinders parental atachment by creating a physical barrier between the mother and the newborn. It also exposes the newborn to potential risks such as dehydration, hyperthermia, or eye damage.

Choice D Reason: Placing the newborn on the maternal abdomen and doing the initial assessment. This is because this intervention facilitates skin to skin contact, eye contact, and bonding between the mother and the newborn. It also enhances breastfeeding initiation, thermoregulation, and maternal-infant atachment.

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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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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: