The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jitery and has a heel stick glucose level of 40 mg/dL (2.2 mmol/L) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first?

Reference range:

Blood glucose neonate: [30 to 60 mg/dL or 1.7 to 3.3 mmol/L]

Oﬀer nipple feedings of 10% dextrose.

Begin frequent feedings of breast milk or formula

Repeat the heel stick for glucose in one hour

Assess for signs of hypocalcemia

Answer and Explanation

The Correct Answer is B

b. Begin frequent feedings of breast milk or formula.

The infant has hypoglycemia, which is a low blood glucose level that can cause jiteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

a. Oﬀering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

c. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

d. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jiteriness.

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Correct Answer is B

No explanation

A. Flaring of the nares. B. A resting respiratory rate of 35 breaths/min. C. Bilateral bronchial breath sounds. D. Diaphragmatic respirations.

Correct Answer is A

Explanation

A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.

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Naxlex Comprehensive Predictor Exams

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Correct Answer is B

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Correct Answer is A

Explanation

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