Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
The labor and delivery nurse is caring for a neonate immediately following vaginal deliveryItem 1 of 1
Nurses' Notes
1105: 37-week neonate born at 1105. Weight at birth was 7 pounds 3 ounces (3316 grams). Head circumference 33 cm; chest circumference 31 cm. The umbilical cord was clamped and cut, revealing two arteries and one vein. Vigorous cry and movement in all extremities were noted. Gluteal folds were symmetrical. Breath sounds clear, and no grunting; pink body and cyanotic extremities. Apical pulse was 119/minute; axillary temperature 96.5┬░F (35.8┬░C); respiratory rate was 50/minute. Pulse oximetry 95% on room air. APGAR at one minute was 9.
Complete the sentence below from the lists of options. The neonate is at greatest risk for------------------due to the neonates -------------and---------------------
Correct answer
E,C,B
Rationale
The neonate is at the greatest risk for hypoglycemia, as evidenced by cyanosis and low axillary temperature. A normal temperature for a newborn is 36.5┬░ to 37.5┬░C (97.7┬░ to 99.5┬░F) axillary.
When the neonate is cold and demonstrating cyanosis, they use more energy, which burns glucose.
Cyanotic extremities are not an expected finding. Please do not confuse this with acrocyanosis, as acrocyanosis is not the entire extremity (it is just the plantar and palmar surfaces).
Cyantotic extremities are a manifestation consistent with cold stress.
The nurse must consider performing a heel stick for a glucose level and closely monitor the neonate for hypoglycemia manifestations, including jitteriness, weakness, crying, hypotonia, tachypnea, grunting, dyspnea, and tachycardia.
Respiratory distress is excluded because the respiratory rate is within normal 30-60/minute parameters, pulse oximetry is optimal, and the lung sounds are clear.
The neonate was born at 37 gestational weeks, which is an early term, and has an adequate weight.
The head circumference is within normal limits and excludes micro- and macrocephaly. The average head circumference is 33 to 35 cm (13.2 to 14 inches), and the normal chest circumference for a term newborn is 30-36 cm (12-14 in).
When the neonate is cold and demonstrating cyanosis, they use more energy, which burns glucose.
Cyanotic extremities are not an expected finding. Please do not confuse this with acrocyanosis, as acrocyanosis is not the entire extremity (it is just the plantar and palmar surfaces).
Cyantotic extremities are a manifestation consistent with cold stress.
The nurse must consider performing a heel stick for a glucose level and closely monitor the neonate for hypoglycemia manifestations, including jitteriness, weakness, crying, hypotonia, tachypnea, grunting, dyspnea, and tachycardia.
Respiratory distress is excluded because the respiratory rate is within normal 30-60/minute parameters, pulse oximetry is optimal, and the lung sounds are clear.
The neonate was born at 37 gestational weeks, which is an early term, and has an adequate weight.
The head circumference is within normal limits and excludes micro- and macrocephaly. The average head circumference is 33 to 35 cm (13.2 to 14 inches), and the normal chest circumference for a term newborn is 30-36 cm (12-14 in).