A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions. Exhibits Complete the diagram by dragging from the choices below to specify: What condition the newborn is most likely experiencing. Two actions the nurse should take to address that condition. Two parameters the nurse should monitor to assess the newborn’s progress.
Explanation & Rationale
Condition: Hypoglycemia. 2 actions: Administer intravenous dextrose as prescribed, Encourage breastfeeding to promote glucose stability. 2 parameters: Blood glucose levels, Muscle tone and reflexes. Rationale for correct condition: The newborn's blood glucose level is critically low at 35 mg/dL, indicating hypoglycemia. Symptoms like jitteriness, decreased muscle tone, poor feeding, and irritability align with neonatal hypoglycemia. Hypoglycemia is common in newborns, especially with the stress of delivery. Early identification and treatment are crucial to prevent complications. The presence of hypoglycemia requires immediate intervention to stabilize the newborn's condition. Rationale for actions: Administering intravenous dextrose is essential to quickly raise the newborn's blood glucose level. Dextrose provides a rapid source of glucose, addressing the immediate hypoglycemia. Encouraging breastfeeding promotes regular feeding, helping to maintain stable blood glucose levels over time. Frequent feeding supports glucose stability. Administering phototherapy treats hyperbilirubinemia, not hypoglycemia. Administering calcium gluconate addresses hypocalcemia, which is secondary here. Gastric lavage is unnecessary for feeding intolerance in this context. Rationale for parameters: Monitoring blood glucose levels is critical to ensure the newborn's glucose levels remain stable. Frequent checks guide the effectiveness of treatment. Muscle tone and reflexes assess neurological responses and improvement with treatment. Changes can indicate recovery from hypoglycemia. Serum bilirubin levels are related to jaundice. Oxygen saturation is stable and unrelated to hypoglycemia. Serum calcium levels monitor hypocalcemia, not directly hypoglycemia. Rationale for incorrect conditions: Neonatal Abstinence Syndrome presents with withdrawal symptoms, not primarily hypoglycemia. Neonatal sepsis would show signs of infection and systemic instability. Hyperbilirubinemia focuses on elevated bilirubin and jaundice.