Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
Nurses' Notes: Newborn lightly swaddled, jittery, weak cry, mottled extremities, acrocyanosis, rapid respirations. History: Gravida 2 Para 2, vaginal birth at 41 weeks, maternal syphilis treated, intermittent cannabis use. Vital Signs: Temp 36┬░C, HR 132/min, RR 72/min, Weight 4,366 g. Diagnostic Results: Maternal blood type A+, RPR/VDRL negative, urine drug screen positive for marijuana.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
Correct answer
A
Rationale
Jitteriness, weak cry, and large birth weight suggest hypoglycemia. Feeding stabilizes glucose, and capillary blood confirms diagnosis. Monitoring respiratory status and temperature assesses progress.