Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry.
What is the top priority nursing action?
Notify the clinician immediately.
Test the blood glucose level.
Start an intravenous line with D5W.
Document the event in the nurse’s notes.
The Correct Answer is B
Choice A rationale
Notifying the clinician immediately may be necessary, but it is not the first action to take. The nurse should first identify the cause of the baby’s symptoms.
Choice B rationale
The baby’s symptoms are indicative of hypoglycemia, a common condition in infants of mothers with diabetes. Testing the blood glucose level would confirm this diagnosis and allow for appropriate treatment.
Choice C rationale
Starting an intravenous line with D5W may be necessary if the baby’s blood glucose level is low. However, the first step should be to confirm the diagnosis by testing the blood glucose level.
Choice D rationale
Documenting the event in the nurse’s notes is important, but it is not the first action to take. The nurse should first address the baby’s immediate needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hyperglycemia, or high blood sugar, is not typically associated with poor feeding and low temperature in infants. It’s more commonly seen in conditions like diabetes.
Choice B rationale
Neonatal infection could cause an infant to feed poorly and have a low temperature. These symptoms could be a sign of sepsis, a serious and potentially life-threatening infection that requires immediate medical attention.
Choice C rationale
Hemolytic anemia, a condition where red blood cells are destroyed faster than they can be made, is not typically associated with poor feeding and low temperature in infants.
Choice D rationale
Prematurity could potentially cause poor feeding and low temperature, but these symptoms would not typically appear suddenly in a well-baby nursery setting.
Correct Answer is D
Explanation
Choice A rationale
The American Cancer Society does not recommend starting mammograms at age 30 for women at average risk. This age is too young for the initiation of routine screening mammograms.
Choice B rationale
The American Cancer Society does not recommend starting mammograms at age 35 for women at average risk. This age is still considered too young for the initiation of routine screening mammograms.
Choice C rationale
The American Cancer Society does not recommend starting mammograms at age 40 for women at average risk, although women between 40 and 44 have the option to start screening with a mammogram every year.
Choice D rationale
According to the American Cancer Society, women at average risk should start having mammograms at age 45. From age 45 to 54, they should get mammograms every year.
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