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) Urine output of 200 mL for the past 8 hours is incorrect because this is a normal finding for a postpartum woman. The average urine output for a healthy adult is about 800 to 2000 mL per day, which means about 100 to 250 mL per hour. Therefore, a urine output of 200 mL for the past 8 hours is within the normal range and does not indicate any complications.
Choice b) Weight decrease of 2 pounds since delivery is incorrect because this is also a normal finding for a postpartum woman. The weight loss is due to the expulsion of the placenta, amniotic fluid, and blood during delivery. A postpartum woman can expect to lose about 10 to 12 pounds immediately after giving birth, and another 5 pounds in the following weeks due to fluid loss. Therefore, a weight decrease of 2 pounds since delivery is not a cause for concern and does not need to be reported to the obstetrician.
Choice c) Pulse rate of 65 beats per minute is incorrect because this is also a normal finding for a postpartum woman. The normal resting pulse rate for an adult ranges from 60 to 100 beats per minute, and it may decrease slightly after delivery due to blood loss and reduced cardiac output. Therefore, a pulse rate of 65 beats per minute is not indicative of any problems and does not require any intervention.
Choice d) Drop in hematocrit of 6% since admission is correct because this is an abnormal finding for a postpartum woman and suggests that she has developed anemia due to excessive blood loss. Hematocrit is the percentage of red blood cells in the blood, and it reflects the oxygen-carrying capacity of the blood. The normal hematocrit range for an adult female is 37% to 47%, and it may decrease slightly after delivery due to hemodilution. However, a drop in hematocrit of more than 10% from the baseline or below 30% indicates severe anemia and requires immediate treatment. Therefore, a drop in hematocrit of 6% since admission is a significant change that should be reported to the obstetrician as soon as possible.
Correct Answer is B
Explanation
Choice A) "Oh, don't worry about that. It's okay." is incorrect because this is not a helpful or informative response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not explain what the black, sticky stuff in the diaper is, why it is there, or how long it will last. It also does not address the father's concern or curiosity, and may make him feel dismissed or ignored. Therefore, this response is inadequate and inappropriate.
Choice B) "That's meconium, which is your baby's first stool. It's normal." is correct because this is a clear and accurate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response explains what the black, sticky stuff in the diaper is, which is meconium. Meconium is a substance that consists of amniotic fluid, mucus, bile, and other waste products that accumulate in the baby's intestines before birth. It is usually passed within the first 24 to 48 hours after birth, and then replaced by transitional or regular stools. Meconium has a dark green or black color and a thick, sticky consistency. It does not have any odor or bacteria. It is normal and harmless for most babies, unless they inhale it during delivery, which can cause breathing problems or infection. Therefore, this response reassures and educates the father about his baby's condition.
Choice C) "That's transitional stool." is incorrect because this is not a true or complete response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not identify what the black, sticky stuff in the diaper is, which is meconium. Transitional stool is a type of stool that appears after meconium and before regular stools. It usually occurs between the second and fifth day after birth, and then changes to yellow or brown stools. Transitional stool has a greenish-brown color and a loose, seedy consistency. It may have some odor or bacteria. It indicates that the baby's digestive system is maturing and adapting to breast milk or formula. Therefore, this response confuses and misleads the father about his baby's condition.
Choice D) "That means your baby is bleeding internally." is incorrect because this is not a valid or appropriate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not describe what the black, sticky stuff in the diaper is, which is meconium. Bleeding internally means that blood vessels are damaged or ruptured inside the body, causing blood loss and shock. This can be caused by various factors such as trauma, infection, clotting disorder, or medication. Bleeding internally can manifest as blood in the stool, urine, vomit, or saliva. However, it does not cause black, sticky stools like meconium. Moreover, this response scares and alarms the father without any evidence or reason. Therefore, this response is false and unethical.
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