The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Ensure the infant breastfeeds in the first hour.

Perform a glucose test for the infant before feeding.

Administer intravenous dextrose infusion within 2 hours.

Ensure the infant is fed every hour for the first 24 hours.

Answer and Explanation

The Correct Answer is A

A.   This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B.   A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D.   While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

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Correct Answer is A

Explanation

A. Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. Contacting the provider for incisional discharge is a proper response.
C. Not having unrelieved pain in the abdomen is an appropriate expectation.
D. Resuming prenatal vitamins is a normal postoperative recommendation.

A. Document this as an expected finding. B. Call the provider to further assess the newborn. C. Prepare the newborn for transport to the NICU. D. Ask another nurse to verify the heart rate.

Correct Answer is A

Explanation

A. An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B. Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D. Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.

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The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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