Practice Question
Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?
Answer Choices:
Correct Answer:
Test for blood glucose level.
Rationale:
🔴 A newborn of an insulin-dependent diabetic mother is at high risk for hypoglycemia due to hyperinsulinemia developed in utero.
🔴After birth, the sudden removal of maternal glucose supply can cause a sharp drop in blood glucose levels.
🔴 Symptoms such as jitteriness, irritability, and a high-pitched cry are classic early signs of neonatal hypoglycemia and warrant immediate blood glucose testing to confirm diagnosis and guide treatment.
🔴 This action is the top priority because prompt identification of hypoglycemia is essential to prevent seizures, brain damage, and long-term neurological deficits.
🔴 While starting IV glucose may be appropriate after confirming hypoglycemia, the priority is to objectively measure the blood sugar first.
🔴 Early detection ensures rapid intervention with oral or IV glucose depending on severity, preventing escalation to more severe complications.
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This question is from RN ATI Maternity Exam II which contains 45 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4