The nurse is preparing to teach the postpartum mom about newborn feeding cues. Which of the following behaviors of the infant would be considered early hunger cues? Select all that apply.
Sucking on their fingers.
Smacking their lips.
Extending their tongue.
Crying.
Rooting.
Correct Answer : A,B,C,E
Choice A rationale
Sucking on their fingers is an early hunger cue in infants. It indicates that the baby is ready to feed.
Choice B rationale
Smacking their lips is another early hunger cue. It shows that the baby is thinking about feeding.
Choice C rationale
Extending their tongue is also an early hunger cue. It indicates that the baby is ready to latch onto the breast or bottle.
Choice D rationale
Crying is a late hunger cue. It is better to feed the baby before they start crying to make feeding easier.
Choice E rationale
Rooting is an early hunger cue. It involves the baby turning their head towards the breast or bottle, indicating they are ready to feed. .
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Correct Answer is B
Explanation
Choice A rationale
Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.
Choice B rationale
Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.
Choice C rationale
Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.
Choice D rationale
Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.
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.