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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Allowing the newborn to continue crying without attempting to soothe the baby is not an appropriate strategy for responsive parenting.
B. Keeping the newborn in the center of a large crib without attending to the baby's needs is not responsive caregiving.
C. Carrying the newborn every time he/she cries may not be practical or necessary, and it's important to encourage safe sleep practices.
D. Swaddling the newborn in a receiving blanket can provide comfort and a sense of security, promoting sleep and reducing crying.

A. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg B. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg C. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg D. Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg

Correct Answer is D

Explanation

A. While the heart rate and respiratory rate are elevated, the blood pressure and temperature are within an acceptable range.
B. The heart rate and respiratory rate are within normal limits, and the blood pressure is elevated but not as concerning as other options.
C. The temperature and blood pressure are within normal limits, and while the heart rate is slightly elevated, it is not as concerning as other options.
D. The elevated heart rate, low blood pressure, and elevated temperature may indicate hypovolemic shock, which is of greatest concern given the history of significant estimated blood loss.

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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

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies are appropriate for the nurse to teach the new mother about her infant?

Correct Answer is D

Explanation

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

Correct Answer is D

Explanation

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