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 D
Explanation
Choice A reason:
Scant scalp hair is not an expected finding for a newborn who is post-term. Scant scalp hair is more common in preterm infants who have not developed fully.
Choice B reason:
Copious vernix is not an expected finding for a newborn who is post-term. Vernix is a white, cheesy substance that covers the skin of the fetus and protects it from the amniotic fluid. Vernix is usually abundant in preterm infants and decreases as gestation progresses.
Choice C reason:
Increased subcutaneous fat is not an expected finding for a newborn who is post-term. Increased subcutaneous fat is a sign of adequate nutrition and growth, which is more likely in term infants. Post-term infants may have reduced subcutaneous fat due to placental insufficiency and decreased nutrient supply.
Choice D reason:
Dry, cracked skin is an expected finding for a newborn who is post-term. Dry, cracked skin is a result of prolonged exposure to the amniotic fluid, which causes dehydration and desquamation of the skin. Post-term infants may also have meconium staining on their skin due to fetal distress.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Cerebral palsy is a disorder that affects movement, posture, and muscle tone. It can be caused by brain damage that occurs before, during, or after birth. Premature babies are at a higher risk of developing cerebral palsy because they are more likely to have bleeding in the brain, lack of oxygen to the brain, infections or other complications that can damage the brain.
Choice B reason:
Color blindness is a condition that affects the ability to see colors or differences in colors. It is usually inherited and not related to prematurity. However, some premature babies may develop retinopathy of prematurity, which can affect their vision in other ways.
Choice C reason:
Learning disabilities are problems that affect the ability to learn, read, write, speak or do math. They can be caused by genetic factors, environmental factors or brain injuries.
Premature babies are more likely to have learning disabilities because they are more likely to have brain damage, low birth weight, infections or other complications that can affect their brain development.
Choice D reason:
Retinopathy is a disease that affects the blood vessels in the retina, the light-sensitive layer of tissue at the back of the eye. Retinopathy of prematurity is a condition that occurs when the blood vessels in the retina grow abnormally in premature babies. This can cause bleeding, scarring or detachment of the retina, which can lead to vision loss or blindness.
Choice E reason:
Apnea is a condition that causes pauses in breathing during sleep. Apnea of prematurity is a condition that affects premature babies who have not fully developed their nervous system and respiratory system. This can cause them to stop breathing for more than 20 seconds at a time, which can lower their oxygen levels and heart rate.
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