Exhibits
A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct answers: Transient hypoglycemia is common in the first hours of life, especially in macrosomic infants due to maternal hyperglycemia-induced fetal hyperinsulinemia. Blood glucose <40–45 mg/dL is abnormal; this newborn had 35 mg/dL initially, improved to 50 mg/dL after feeding. Symptoms like jitteriness, abnormal cry, and mild hypotonia resolved post-breastfeeding. Breastfeeding provides lactose, which is hydrolyzed to glucose and galactose, correcting hypoglycemia physiologically. Early feeding is first-line for asymptomatic or mildly symptomatic neonates with glucose >25 mg/dL.
Rationale for incorrect Response 1 options: Signs of infection (e.g., temperature instability, poor feeding, lethargy) may overlap with hypoglycemia but require systemic signs and lab confirmation. This newborn improved with feeding and had no fever, tachypnea, or leukocytosis. Respiratory distress presents with grunting, nasal flaring, retractions, and desaturation. The newborn’s respiratory rate was normal (45/min), no distress signs noted. Hyperbilirubinemia manifests as jaundice, typically after 24 hours. No yellowing of skin or sclera was reported; phototherapy is not indicated.
Rationale for incorrect Response 2 options: Administer antibiotics is appropriate for suspected sepsis, not isolated hypoglycemia. No infectious signs or risk factors were present. Provide oxygen support is reserved for respiratory compromise. The newborn had stable vitals and no hypoxia. Initiate phototherapy treats elevated bilirubin. No bilirubin levels or jaundice signs were documented.
Take-home points:
- Transient neonatal hypoglycemia is common in macrosomic infants due to hyperinsulinemia.
- Early breastfeeding is the preferred intervention for mild hypoglycemia with stable vitals.
- Differentiate hypoglycemia from sepsis and respiratory distress using targeted clinical signs.
- Phototherapy is reserved for hyperbilirubinemia; not indicated without jaundice or elevated bilirubin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Loosely wrapping the cord is an important secondary intervention for prolapsed umbilical cord but is not the immediate first action. The priority is to relieve pressure on the cord to maintain fetal oxygenation by reducing compression and sustaining blood flow until delivery can be safely achieved.
Choice B rationale
Assisting the client into a knee-chest position (or Trendelenburg) is the immediate priority action for an umbilical cord prolapse. This maternal position uses gravity to shift the presenting fetal part off the umbilical cord, immediately relieving compression and restoring blood flow to the fetus, preventing fetal hypoxia.
Choice C rationale
Applying an external fetal monitor is a vital step for continuous fetal assessment, but it is not the first action in this emergency. Relieving the cord compression and ensuring adequate oxygenation by changing the maternal position takes precedence over monitoring the fetal heart rate, which will likely be non-reassuring due to the cord compression.
Choice D rationale
Administering high-flow oxygen to the mother is an important intervention to maximize maternal-fetal oxygen transfer and improve fetal oxygenation. However, restoring placental blood flow by relieving the cord compression via proper maternal positioning is the physiologically immediate and most critical action to prevent fetal injury.
Correct Answer is C
Explanation
Choice A rationale
Applying vitamin E oil to the nipples is not generally recommended; it offers little benefit and could potentially introduce unnecessary substances to the infant during feeding. Lanolin cream or purified lanolin is often recommended for sore nipples because it provides moisture, promotes healing by creating a barrier, and is safe for the baby to ingest. Proper latch technique is the primary intervention for preventing nipple soreness.
Choice B rationale
Limiting feeding time to 5 to 10 minutes per breast is incorrect and can lead to inadequate milk intake and insufficient stimulation for milk production. The infant should be allowed to feed for as long as they actively suckle and swallow, usually 15 to 20 minutes or until the breast feels softer, ensuring they receive the higher-calorie hindmilk.
Choice C rationale
Positioning the baby on a pillow at the level of the breast promotes a more comfortable and effective latch. Proper positioning allows the infant's mouth to be level with the nipple, ensuring the baby can take in a large portion of the areola and preventing strain on the mother's back, which facilitates a deeper and more comfortable latch for effective milk transfer.
Choice D rationale
Ensuring just the nipple is in the baby's mouth is an incorrect technique and is a common cause of nipple soreness and inadequate milk transfer. The baby needs to take in a large portion of the areola to effectively compress the milk sinuses underneath, achieving a deep latch that stimulates milk release and minimizes nipple trauma.
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