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 C
Explanation
Choice A reason:
Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.
Choice B reason:
Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.
Choice C reason:
Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.
Choice D reason:
Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus is a port-wine stain, a type of birthmark that is present at birth and does not fade over time. It is caused by a malformation of capillaries in the skin and appears as a reddish-purple patch. It can occur anywhere on the body but is not associated with swelling or suture lines.
Choice B reason:
Cephalhematoma is a collection of blood under the periosteum of the skull bone, usually caused by trauma during delivery. It appears as a swollen area on the head that does not cross the suture line because it is limited by the boundaries of the bone. It usually resolves within a few weeks or months without treatment.
Choice C reason:
Molding is the temporary change in the shape of the newborn's head due to the pressure of the birth canal during delivery. It results in an elongated or cone-shaped head that may cross the suture line. It usually resolves within a few days as the skull bones return to their normal position.
Choice D reason:
Caput succedaneum is a localized swelling of the scalp, usually caused by pressure from the cervix or vacuum extraction during delivery. It appears as a soft, puffy area on the head that crosses the suture line because it is not limited by the bone. It usually resolves within a few days without treatment.
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