Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?
Document the event in the nurses' notes.
Test for blood glucose level.
Notify the clinician stat.
Start an intravenous line with D5W.
The Correct Answer is B
Choice a) Document the event in the nurses' notes is incorrect because this is not a priority action for a neonate who is showing signs of hypoglycemia. Hypoglycemia is a condition where the blood glucose level is lower than normal, which can cause neurological and metabolic problems in newborns. Neonates of diabetic mothers are at higher risk of developing hypoglycemia due to increased insulin production and decreased glycogen stores.
Documenting the event in the nurses' notes is an important step, but it should be done after assessing and treating the neonate's condition.
Choice b) Test for blood glucose level is correct because this is the most important action for a neonate who is exhibiting symptoms of hypoglycemia. The nurse should use a heel stick or a cord blood sample to measure the blood glucose level of the neonate as soon as possible, as hypoglycemia can lead to serious complications such as seizures, coma, brain damage, or death if left untreated. The normal blood glucose range for a full-term neonate is 40 to 60 mg/dL in the first hour of life, and 50 to 90 mg/dL thereafter. A blood glucose level below 40 mg/dL indicates hypoglycemia and requires immediate intervention.
Choice c) Notify the clinician stat is incorrect because this is not the most urgent action for a neonate who is suffering from hypoglycemia. The nurse should notify the clinician after confirming the diagnosis of hypoglycemia and initiating treatment, such as feeding or administering intravenous glucose. The clinician may order further tests or treatments depending on the severity and cause of the hypoglycemia, but the nurse should not delay the initial management of the neonate's condition.
Choice d) Start an intravenous line with D5W is incorrect because this is not the first-line treatment for a neonate who has hypoglycemia. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the neonate. However, before starting an intravenous line with D5W, the nurse should first attempt to feed the neonate with breast milk or formula, as this can also raise the blood glucose level and provide other nutrients and antibodies. If feeding is unsuccessful or contraindicated, then the nurse should start an intravenous line with D5W as ordered by the clinician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Increase oral intake of water between feedings is incorrect because this is not a helpful or recommended measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Bilirubin is a yellow pigment that is produced when red blood cells are broken down. It is normally excreted by the liver into bile and then eliminated by the intestines. However, some newborns have high levels of bilirubin in their blood, which can cause jaundice, a condition that makes the skin and eyes look yellow. Phototherapy is a treatment that uses blue light to help break down the bilirubin and make it easier for the liver to process. Increasing oral intake of water between feedings does not have any effect on the bilirubin level, as water does not contain any nutrients or calories that can stimulate the liver or bowel function. Moreover, giving water to a newborn can cause hyponatremia, which is a low level of sodium in the blood that can lead to seizures, brain damage, or death. Therefore, this measure should be avoided or used with caution for newborns who are receiving phototherapy.
Choice B) Wrap the infant in triple blankets to prevent cold stress during phototherapy is incorrect because this is not a safe or appropriate measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Cold stress is a condition that occurs when a newborn loses too much heat and has difficulty maintaining a normal body temperature. It can cause complications such as hypoglycemia, hypoxia, acidosis, or bleeding. Wrapping the infant in triple blankets may seem like a good way to prevent cold stress, but it can actually cause overheating, dehydration, or hyperthermia, which are equally dangerous for the newborn. Moreover, wrapping the infant in blankets can reduce the effectiveness of phototherapy, as it blocks the exposure of the skin to the blue light. Therefore, this measure should be avoided or used with caution for newborns who are receiving phototherapy.
Choice C) How to prepare the newborn for an exchange transfusion is incorrect because this is not a relevant or necessary measure to help reduce the bilirubin in a newborn who is receiving phototherapy. An exchange transfusion is a procedure that involves replacing some of the newborn's blood with donor blood to lower the bilirubin level and prevent brain damage. It is usually reserved for severe cases of jaundice that do not respond to phototherapy or other treatments. Preparing the newborn for an exchange transfusion involves obtaining informed consent from the parents, placing an umbilical venous catheter, monitoring vital signs and blood tests, and administering medications and fluids. However, these steps are not part of routine care for newborns who are receiving phototherapy, and they do not help to reduce the bilirubin level by themselves. Therefore, this measure should be done only when indicated by the physician and explained by the nurse.
Choice D) Increase the frequency of feedings is correct because this is an effective and recommended measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Feeding provides nutrients and calories that can stimulate the liver and bowel function, which are essential for processing and eliminating bilirubin from the body. Feeding also helps to prevent dehydration, which can worsen jaundice and increase the risk of complications.
Feeding can be done by breast milk or formula, depending on the mother's preference and availability. The frequency of feedings should be increased to at least every 2 to 3 hours or on demand, as long as the newborn shows signs of hunger and satisfaction. Therefore, this measure should be encouraged and supported by the nurse for newborns who are receiving phototherapy.
Correct Answer is D
Explanation
Choice A) Decreased metabolic rate is incorrect because this is not a result of hypothermia in the newborn, but rather a cause of it. Metabolic rate is the speed at which the body uses energy to perform its functions. Newborns have a high metabolic rate, which helps them to maintain a normal body temperature of 36.5°C to 37.5°C (97.7°F to 99.5°F). However, some factors can lower the metabolic rate of newborns, such as prematurity, low birth weight, infection, or hypoglycemia. A low metabolic rate can make the newborn more susceptible to heat loss and hypothermia, which is a condition that occurs when the body temperature drops below 36°C (96.8°F). Therefore, this response is inaccurate and misleading.
Choice B) Decreased oxygen demands is incorrect because this is not a result of hypothermia in the newborn, but rather a consequence of it. Oxygen demand is the amount of oxygen that the body needs to function properly.
Newborns have a high oxygen demand, which helps them to support their growth and development. However, some factors can decrease the oxygen demand of newborns, such as hypothermia, sedation, or asphyxia. A low oxygen demand can impair the oxygen delivery and utilization by the tissues and organs, leading to hypoxia, acidosis, or organ failure. Therefore, this response is irrelevant and inaccurate.
Choice C) Shivering to generate heat is incorrect because this is not a result of hypothermia in the newborn, but rather a mechanism that is absent in them. Shivering is an involuntary contraction of the muscles that produces heat and raises the body temperature. It is a common response to cold exposure in adults and older children, but not in newborns. Newborns do not have the ability to shiver, as their muscles are immature and lack glycogen stores.
Instead, they rely on other methods to generate heat, such as non-shivering thermogenesis, which involves burning brown fat in certain areas of the body. Therefore, this response is irrelevant and inaccurate.
Choice D) Increased glucose demands is correct because this is a result of hypothermia in the newborn that can cause complications. Glucose demand is the amount of glucose that the body needs to produce energy and maintain its functions. Newborns have a high glucose demand, which helps them to support their metabolic rate and thermoregulation. However, some factors can increase the glucose demand of newborns, such as hypothermia, stress, or infection. A high glucose demand can deplete the glucose stores and cause hypoglycemia, which is a low level of glucose in the blood that can lead to seizures, brain damage, or death. Therefore, this response is clear and accurate.
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