A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
Xiphoid process.
Fifth intercostal space.
Sternal notch.
Nipple line.
The Correct Answer is D
Choice A rationale
The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.
Choice B rationale
The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.
Choice C rationale
The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.
Choice D rationale
The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.
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Correct Answer is D
Explanation
Choice A rationale
Hyperbilirubinemia, or high levels of bilirubin in the blood, can occur in newborns of diabetic mothers due to increased red blood cell breakdown. However, it is not the primary concern immediately after birth. The priority is to address conditions that can cause immediate harm, such as hypoglycemia.
Choice B rationale
Hypomagnesemia, or low magnesium levels, can occur in newborns of diabetic mothers, but it is not the most critical issue. Magnesium levels can be monitored and corrected if necessary, but hypoglycemia poses a more immediate threat to the newborn’s health.
Choice C rationale
Hypocalcemia, or low calcium levels, can also occur in newborns of diabetic mothers. While it is important to monitor and manage calcium levels, hypoglycemia is a more urgent concern because it can lead to severe complications if not addressed promptly.
Choice D rationale
Hypoglycemia, or low blood sugar levels, is the most critical concern for newborns of diabetic mothers. These newborns are at high risk for hypoglycemia due to the high levels of insulin they produce in response to their mother’s elevated blood glucose levels during pregnancy. Hypoglycemia can cause serious complications, including seizures and brain damage, if not treated immediately.
Correct Answer is A
Explanation
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 shouldadminister 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.