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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •

Choice B reason:

Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •

Choice C reason:

Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •

Choice D reason:

Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.

A. "My baby will be placed under special lights if the test is elevated.". B. "This test checks for a genetic disorder that can be corrected by diet.". C. "Sometimes the test is repeated in the doctor's office at the 2-week check-up.". D. "My baby must take formula or breast milk before the test is done.".

Correct Answer is D

Explanation

Choice A reason:

This statement is incorrect because special lights are used to treat jaundice, not PKU. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood. Bilirubin is a waste product that is normally removed by the liver. Special lights help break down bilirubin so that it can be excreted from the body.

Choice B reason:

This statement is correct because PKU is a genetic disorder that can be corrected by diet. PKU is caused by a lack of an enzyme that breaks down phenylalanine, an amino acid found in protein-rich foods. Phenylalanine can build up in the blood and cause brain damage and other health problems if not treated. A diet that is low in phenylalanine and high in a special formula can prevent these complications.

Choice C reason:

This statement is correct because sometimes the test is repeated in the doctor's office at the 2-week check-up. The PKU test is done one to three days after birth, but it may not be accurate if the baby has not had enough protein in their diet before the test. A repeat test may be needed to confirm or rule out PKU.

Choice D reason:

This statement is incorrect because the baby must take formula or breast milk after the test is done, not before. The test measures the level of phenylalanine in the blood, which will be higher if the baby has eaten protein-rich foods. The test should be done after the baby has fasted for at least two hours.

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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?

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