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The nurse reinforces teaching regarding newborn hypoglycemia.

Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.

Glucose levels of 40 to 45 mg/dL are considered the normal lower limit for up to 72 hours after birth.

If my baby's blood glucose keeps going below 50 mg/dL in the next 24 hours, they will need intravenous glucose.

When my umbilical cord was clamped, my baby lost its source of glucose.

As long as I breastfeed my baby frequently, their blood glucose levels should improve.

It is common for term newborns to experience transient hypoglycemia within the first few hours of life.

The skin-to-skin contact immediately after birth promotes thermoregulation and stabilizes glucose levels.

Answer and Explanation

Correct Answer : C,D,E,F

Choice A rationale

Neonatal hypoglycemia is typically defined as a blood glucose concentration below 40 mg/dL in the first 4 hours of life, or below 45 mg/dL between 4 and 24 hours. Glucose levels of 40 to 45 mg/dL are generally considered the goal range to prevent neurological injury, not the normal lower limit for up to 72 hours post-birth.

Choice B rationale

If a newborn's blood glucose levels remain persistently below 40 mg/dL after initial management (like feeding) or if they develop symptomatic hypoglycemia, intravenous dextrose will be required. A value persistently below 50 mg/dL is concerning, but the 40 mg/dL threshold is often the critical point for initiating IV glucose when oral methods fail.

Choice C rationale

The umbilical cord provides the fetus with a continuous supply of glucose via the placenta from the mother. Upon umbilical cord clamping, this maternal glucose supply is abruptly interrupted, requiring the newborn's immature metabolic systems to take over glucose homeostasis. This sudden loss of exogenous glucose is a primary factor in transient newborn hypoglycemia.

Choice D rationale

Frequent breastfeeding provides the newborn with a readily available source of lactose, which is metabolized into glucose, thereby promoting the stability of their blood glucose levels. Early and frequent feeding is the primary intervention for transient hypoglycemia in newborns who are able to feed, utilizing the oral route for caloric intake.

Choice E rationale

Transient hypoglycemia is a common and expected physiological adaptation in term newborns during the initial hours after birth. The abrupt cessation of maternal glucose supply necessitates the newborn's activation of gluconeogenesis and glycogenolysis, which may temporarily be insufficient, leading to a mild, self-limiting drop in blood glucose.

Choice F rationale

Skin-to-skin contact immediately after birth is vital as it prevents cold stress. When a newborn is cold, they must expend energy (calories) to produce heat, which consumes glucose, potentially leading to or exacerbating hypoglycemia. Thermoregulation thus indirectly stabilizes blood glucose levels by conserving energy.

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Correct Answer is A

Explanation

Choice A rationale

Transcutaneous electrical nerve stimulation (TENS) operates on the Gate Control Theory of Pain, where non-painful electrical stimuli are applied, attempting to block the transmission of pain signals. The intensity must be manually increased by the client during a contraction to override the escalating pain impulse and achieve maximum analgesic effect when the pain is most intense, providing the best pain modulation.

Choice B rationale

TENS is primarily used for the low back pain and abdominal pain experienced during the active phase of the first stage of labor (cervical dilation), providing a distraction and non-pharmacological pain relief option. It is less effective during the second stage (pushing) and is not typically indicated for the third stage of labor (placental expulsion), which has different pain mechanisms.

Choice C rationale

TENS works by stimulating large sensory nerve fibers to modulate or decrease the perception of pain (pain modulation), offering a sense of control and relief, but it does not eliminate the pain entirely, particularly the intense visceral pain of uterine contractions. It is a non-invasive pain coping mechanism, not an anesthetic agent that would abolish pain sensation.

Choice D rationale

Gestational diabetes mellitus (GDM) is a maternal metabolic condition and is not a contraindication for the use of TENS during labor. The primary contraindications for TENS include the use of a cardiac pacemaker, application over the heart or head, or in the presence of fetal electronic monitoring electrodes that could conduct the current, none of which are related to GDM.

A. Babinski reflex. B. Heart rate. C. Moro reflex. D. Blood glucose.

Correct Answer is B

Explanation

Choice A rationale

The Babinski reflex is a primitive neurological reflex tested by stroking the sole of the foot. A normal response in a newborn is fanning of the toes, which indicates an intact central nervous system. This reflex, though important for neurological assessment, does not provide immediate data for evaluating respiratory or muscle tone complications, which are assessed by other parameters.

Choice B rationale

Heart rate is a critical component of the Apgar score, along with muscle tone, reflex irritability, color, and respiration. A low or declining heart rate (normal range 120-160 beats/min in a newborn) is often an early and sensitive indicator of hypoxia, circulatory compromise, or significant physiological distress, making it essential for immediate complication assessment.

Choice C rationale

The Moro reflex (startle reflex) is a primitive reflex observed by a sudden change in position. Its presence indicates neurological integrity. While its absence could signal a neurological or musculoskeletal injury, it is not an immediate parameter used for rapid assessment of cardiorespiratory stability in a distressed newborn like heart rate or blood glucose.

Choice D rationale

Blood glucose (normal 40-60 mg/dL) is important for energy homeostasis, and hypoglycemia can lead to lethargy, hypotonia, and respiratory distress. However, it is not as rapid or direct a measure of immediate oxygenation and perfusion status as the heart rate and respiratory effort are for determining acute complications.

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The nurse reinforces teaching regarding newborn hypoglycemia. Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the use of a transcutaneous electrical nerve stimulation (TENS) device for back pain during labor. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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The nurse reinforces teaching regarding newborn hypoglycemia.

Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.