Difficulty: Medium
Average Score: 88%
Simulated
Passage / Scenario
Newborn delivered via cesarean birth approximately 1 hour ago. Apgar scores: 8 and 9. Vitamin K administered. Weight: 4337 grams (9 lb 9 oz). Gestational age: 39 weeks. Condition: Large for gestational age. Observations: Newborn noted to be jittery and have decreased muscle toneComplete the diagram by specifying: 1. The potential condition the newborn is most likely experiencing. 2. Two actions the nurse should take to address that condition. 3. Two parameters the nurse should monitor to assess the newborn's progress.
Correct answer
A
Rationale
The correct answer is A: Hypoglycemia. Newborns are at risk for hypoglycemia due to inadequate glycogen stores. The nurse should immediately provide a glucose solution orally or intravenously and monitor blood glucose levels closely. Monitoring vital signs and neurological status are crucial parameters to assess the newborn's progress. Hypoglycemia can lead to serious complications if left untreated.
B: Cytomegalovirus Infection - Unlikely in immediate newborn period.
C: Hyperbilirubinemia - Common but not typically associated with immediate critical condition.
D: Neonatal Abstinence Syndrome - Can occur but not the most likely condition in this scenario.
B: Cytomegalovirus Infection - Unlikely in immediate newborn period.
C: Hyperbilirubinemia - Common but not typically associated with immediate critical condition.
D: Neonatal Abstinence Syndrome - Can occur but not the most likely condition in this scenario.