Four hours after the birth of a healthy neonate of an ...

[Chelseaamend]

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?
 
  a. Notify the clinician stat.
  b. Test for the blood glucose level.
  c. Start an intravenous line with D5W.
  d. Document the event in the nurses' notes.

Question 2

Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome?
 
  a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin
  b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes
  c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes
  d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension

[ynlevi]

Answer to Question 1

ANS: B
These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.

Answer to Question 2

ANS: C
Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.