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 B
Explanation
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
Correct Answer is B
Explanation
A. Enrolling the UAP in a hospital education class on conducting safe client care is unnecessary at this moment. The immediate concern is ensuring the client's safety during the procedure.
B. Stopping the procedure and instructing the UAP to place the client in Fowler's position (or at least semi-Fowler's) is the correct action. This position helps prevent aspiration during oral hygiene for an unconscious client.
C. Praising the UAP for performing oral hygiene does not address the safety risk present in this situation. While family participation is encouraged, it should not be the focus here.
D. Telling the UAP to continue because the unconscious client is positioned safely is incorrect, as the flat side-lying position increases the risk of aspiration. Ensuring the client is positioned properly is essential for their safety.
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