Author Question: The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and ... (Read 88 times)

geodog55 · **on:** Jun 28, 2018

The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infant's blood glucose level is 36 mg/dL. Which action should the nurse implement?

a. Bring the infant to the mother and initiate breastfeeding.
b. Place a nasogastric tube and administer 5 dextrose water.
c. Start a peripheral intravenous line and administer 10 dextrose.
d. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.

Question 2

What is an infant with severe jaundice at risk for developing?

a. Encephalopathy
b. Bullous impetigo
c. Respiratory distress
d. Blood incompatibility

duy1981999 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5 dextrose water or a peripheral intravenous line with 10 dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.

Answer to Question 2

ANS: A
Unconjugated bilirubin, which can cross the bloodbrain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.