A nurse is caring for a neonate in the neonatal unit.
History and Physical
The neonate was delivered via vaginal birth approximately 1 hour ago. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Vitamin K was administered in the left vastus lateralis. The neonate weighs 4337 grams (9 lb 9 oz) and is 52 cm (20.5 in) in length. Gestational age assessment indicates 39 weeks, and the neonate is classified as large for gestational age.
Nurses Notes
The neonate is noted to be jittery and has decreased muscle tone. The neonate’s skin appears slightly mottled, and there is a weak cry. The neonate is also observed to have poor feeding and is irritable when handled. The mother reports that the neonate has not passed urine since birth. The neonate’s reflexes appear diminished.
Vital Signs
- Heart rate: 170/min (apical)
- Respiratory rate: 68/min (auscultation)
- Temperature: 36.1°C (96.9°F) (axillary)
Diagnostic Results
Blood glucose level is 30 mg/dL. A complete blood count (CBC) shows a slightly elevated white blood cell count. Serum calcium levels are within normal limits. Blood culture results are pending.
Physical Examination Results
The neonate exhibits signs of hypoglycemia, including jitteriness and decreased muscle tone. The skin is slightly mottled, and the neonate has a weak cry. There is poor feeding and irritability when handled. Reflexes are diminished, and the neonate has not passed urine since birth.
Which of the following actions should the nurse take first?
Administer a bolus of intravenous glucose.
Reassess the neonate’s blood glucose level in 30 minutes.
Initiate feeding with formula or breast milk.
Place the neonate under a radiant warmer.
The Correct Answer is A
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse should administer a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.
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Correct Answer is C
Explanation
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.
Correct Answer is C
Explanation
Choice A rationale
Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.
Choice B rationale
Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.
Choice C rationale
Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.
Choice D rationale
Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.