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
The Correct Answer is B
A. Offering 10% dextrose via nipple feeding is used for infants who are unable to feed orally or with severe hypoglycemia. This neonate is still within range hence dextrose is not incicated at this point.
B. The infant is jittery with a glucose of 40 mg/dL, which indicates mild symptomatic hypoglycemia. Initiating frequent feedings of breast milk or formula is the first action to stabilize glucose while supporting oral intake.
C. Repeating the heel stick is important for monitoring, but it does not treat the low glucose and is not the first action.
D. Assessing for hypocalcemia may be indicated later, but the priority is addressing hypoglycemia through feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.
Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.
B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are typically assessed to evaluate circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.
Correct Answer is D
Explanation
A) Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B) Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C) Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D) Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.
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