Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?
a. Monitor blood pressure closely.
b. Obtain urine sample to detect glycosuria.
c. Obtain serum glucose and serum calcium levels.
d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
ANS: C
These are signs and symptoms of hypocalcemia and hypoglycemia. A blood test is useful to determine the treatment. Laboratory analysis for calcium and blood glucose should be the priority intervention. Monitoring vital signs is important, but recognition of the possible hypocalcemia and hypoglycemia is imperative. A finding of glycosuria would not facilitate the diagnosis of hypoglycemia. A determination must be made between the hypocalcemia and hypoglycemia before treatment can be initiated.
You might also like to view...
The nurse is creating a care plan for a patient admitted with severe bone pain related to an infected leg wound. Which diagnosis written on the plan indicates an understanding of the components of a nursing diagnosis? (Select all that apply.)
a. Acute pain b. Risk for impaired walking c. Ineffective bone tissue perfusion d. Osteomyelitis e. Infection
A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient's medication regimen, what nursing diagnosis should be prioritized?
A) Risk for injury B) Risk for infection C) Risk for peripheral neurovascular dysfunction D) Risk for unstable blood glucose
A resident in a long-term care facility has difficulty swallowing and frequently chokes on food and liquids. Because of the threat of aspiration, the nurse initiates a referral for swal-lowing evaluation to a:
1. doctor specializing in throat disorders. 2. dietitian. 3. nutritionist. 4. speech therapist.
The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows the client education was successful when the client states, "During labor, the nurse will:
1. "Check my cervix by doing a pelvic exam every two hours.". 2. "Assess the baby's heart rate with an electronic fetal monitor.". 3. "Look at the color and amount of bloody show that I have.". 4. "Verify that my contractions are strong but not too close together.".