The nurse checks the blood sugar of a 2 hour old newborn, and the glucometer reading is 32 mg/dl. Which action should the nurse take next?
Transfer the newborn to the NICU
Call the lab for a STAT blood glucose level
Initiate breastfeeding
Recognize this as a normal reading and document it
The Correct Answer is C
Choice A reason:
Transferring the newborn to the NICU is not the best action to take next, because it does not address the immediate problem of low blood sugar. The newborn may need to be transferred to the NICU later, depending on the cause and severity of the hypoglycemia, but the first priority is to raise the blood glucose level.
Choice B reason:
Calling the lab for a STAT blood glucose level is not the best action to take next, because it will delay the treatment of hypoglycemia. The glucometer reading is a reliable indicator of low blood sugar, and waiting for a lab confirmation will waste valuable time. The nurse should act on the glucometer reading and initiate treatment as soon as possible.
Choice C reason:
Initiating breastfeeding is the best action to take next, because it will provide the newborn with a source of glucose that can raise the blood sugar level quickly. Breastfeeding also has other benefits for the newborn, such as promoting bonding, providing antibodies, and reducing the risk of infection. Breastfeeding should be initiated within the first hour of life for all newborns, unless contraindicated.
Choice D reason:
Recognizing this as a normal reading and documenting it is not the best action to take next, because it is not a normal reading for a 2 hour old newborn. The normal range of blood glucose for a newborn is 40 to 150 mg/dL. A reading of 32 mg/dL indicates hypoglycemia, which can have serious consequences for the newborn's brain development and function. Hypoglycemia should be treated promptly and documented accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
This is incorrect because TTN usually resolves within 24 to 72 hours of birth and does not require a long stay in the NICU.
Choice B reason:
This is correct because TTN is more common in babies born by cesarean section without labor, as they do not have the hormonal changes that help clear the fetal lung fluid.
Choice C reason:
This is incorrect because breastfeeding is not contraindicated in babies with TTN, unless they have severe respiratory distress or need continuous positive airway pressure (CPAP) support.
Choice D reason:
This is incorrect because TTN does not cause chronic lung disease or require oxygen therapy at home. Most babies with TTN only need supplemental oxygen for a few days until their breathing improves.
Correct Answer is ["A","C"]
No explanation
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