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
Hot flashes are typically associated with menopause, not endometriosis. They occur due to changes in hormone levels, particularly a decrease in estrogen.
Choice B rationale
Dyspareunia, or painful intercourse, is a common symptom of endometriosis. The condition can cause adhesions and lesions in and around the pelvic organs, leading to pain during sexual activity.
Choice C rationale
Fluid retention is not specifically associated with endometriosis. It can occur due to a variety of conditions, including hormonal changes, dietary factors, and certain medications.
Choice D rationale
Fever is not a typical symptom of endometriosis. It’s more commonly associated with infections or inflammatory conditions.
Correct Answer is D
Explanation
Choice A rationale
A Pap smear is not helpful in identifying ovarian cancer. It is used to detect cervical cancer, not ovarian cancer.
Choice B rationale
While the CA-125 blood test can indicate the presence of ovarian cancer if the levels are elevated, it is not a reliable screening test. This is because high levels of CA-125 can also be caused by common conditions such as endometriosis and pelvic inflammatory disease.
Choice C rationale
Genetic testing for two genes (BRCA1 and BRCA2) can identify an increased risk for developing ovarian cancer, but it does not diagnose the disease itself.
Choice D rationale
Currently, there is no reliable screening test for ovarian cancer. The most effective strategies for early detection are being aware of the symptoms and maintaining regular check-ups with your healthcare provider.
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