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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

During a routine evaluation of a full-term neonate who is 2 hours old, the nurse notes an axillary temperature of 97.1°F (36.2°C). The infant appears lethargic, has a weak cry, and exhibits fine tremors in both hands when undisturbed. Which of the following is the most appropriate action for the nurse to take first?

  1. A
    Tell the parents not to worry because infants frequently experience temporary temperature drops after birth
  2. B
    Instruct the assistive personnel to place the infant under a radiant warmer and monitor the vital signs
  3. C
    Document the hand movements as a normal Moro reflex and wrap the infant in an extra blanket
  4. Obtain a heel-stick blood glucose reading and report the findings to the registered nurseCevap

Cevap

Obtain a heel-stick blood glucose reading and report the findings to the registered nurse.
The correct answer addresses the immediate physiological risk to the neonate. A temperature of 97.1°F (36.2°C) is below the expected normal range (97.7°F - 99.5°F) and indicates hypothermia, which triggers cold stress. In response to cold stress, the newborn's body rapidly consumes glucose to generate heat, frequently leading to hypoglycemia. Tremors, lethargy, and a weak cry are classic signs of neonatal hypoglycemia. Within the practical nurse's scope of practice, obtaining a capillary blood glucose reading and promptly notifying the registered nurse is the highest priority to prevent irreversible neurological complications.

Adım Adım Çözüm

1
Analyze the infant's clinical presentation.
The neonate has hypothermia (97.1°F / 36.2°C), lethargy, a weak cry, and resting tremors.
Identifying abnormal assessment data is the first step in recognizing physiological instability.
2
Connect the symptoms to a pathophysiological process.
Cold stress increases metabolic demands, rapidly depleting glycogen stores and causing hypoglycemia, which manifests neurologically as lethargy and tremors.
Understanding the physiological link between thermoregulation and blood glucose directs the appropriate intervention.
3
Determine the priority nursing action within the practical nurse's scope of practice.
The nurse must collect objective data regarding the blood glucose level and immediately escalate the findings.
Hypoglycemia can cause severe neurological damage if untreated, requiring rapid identification and reporting to the registered nurse or provider.

Anahtar Kavram

Neonatal Cold Stress and Hypoglycemia
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Ante/Intra/Postpartum and Newborn Care

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