Exhibits

The nurse is assisting in the initiation of phototherapy. For each nursing action, specify if the action is indicated or not indicated for the newborn.

 

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.

Choice A rationale

This statement is incorrect. While lactational amenorrhea method (LAM) offers some protection, it is only highly effective under strict conditions: amenorrhea, exclusive breastfeeding, and less than six months postpartum. Ovulation can resume even while breastfeeding, so additional contraception is often necessary to prevent unintended pregnancy.

Choice B rationale

There is no scientific evidence to support the claim that taking birth control pills while breastfeeding increases the risk for breast cancer. This statement is false and should not be used to counsel the client. The primary concern with combined estrogen-progestin pills in lactating women is the potential suppression of milk supply.

Choice C rationale

Combined estrogen-progestin birth control pills are generally contraindicated or strongly discouraged during the initial weeks to months of breastfeeding. The estrogen component can decrease the quantity and quality of breast milk, potentially interfering with successful lactation. However, progestin-only pills are considered safe and not contraindicated.

Choice D rationale

Progestin-only birth control pills (the "mini-pill") are the preferred hormonal contraceptive for lactating clients. The absence of estrogen means they are less likely to negatively impact breast milk supply or composition. Progestin-only pills primarily work by thickening cervical mucus and inhibiting ovulation, offering effective contraception while minimizing risks to the breastfeeding infant.