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.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.
Correct Answer is C
Explanation
A) Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B) Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C) Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D) Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.
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