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 B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
Correct Answer is C
Explanation
Choice A) dilates the bronchioles, decreasing airway resistance: This is not the correct function of surfactant.
Surfactant is a substance that reduces the surface tension of the fluid that lines the alveoli, which are the tiny air sacs in the lungs where gas exchange occurs. Surfactant does not affect the diameter of the bronchioles, which are the small airways that branch from the bronchi. Bronchodilation and bronchoconstriction are regulated by the autonomic nervous system and various mediators, such as histamine, epinephrine, and acetylcholine.
Choice B) provides transportation for oxygen to enter the blood supply: This is not the correct function of surfactant. Surfactant does not transport oxygen or any other gas. Oxygen diffuses from the alveoli into the capillaries, where it binds to hemoglobin in the red blood cells. The red blood cells then transport oxygen to the tissues via the blood circulation. Surfactant does not play a role in this process.
Choice C) keeps the alveoli open during expiration: This is the correct function of surfactant. Surfactant prevents the alveoli from collapsing during expiration by lowering the surface tension of the fluid that lines them. This allows for easier breathing and better gas exchange. Without enough surfactant, the alveoli tend to collapse and stick together, causing atelectasis, which is a condition where some or all of a lung collapses. Atelectasis can lead to hypoxia, respiratory distress, and infection.
Choice D) causes increased permeability of the alveoli: This is not the correct function of surfactant. Surfactant does not increase or decrease the permeability of the alveoli, which is the ability of substances to pass through them.
Permeability of the alveoli depends on several factors, such as pressure gradients, solubility, molecular size, and membrane thickness. Increased permeability of the alveoli can occur in conditions such as acute respiratory distress syndrome (ARDS), where fluid leaks into the alveolar space and impairs gas exchange. Surfactant does not cause this condition, but it can be affected by it.
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