Practice Quiz

NCLEX-PN

Category - Reduction of Risk

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A client with uncontrolled gestational diabetes gives birth at 37 weeks to a baby boy who weighs 4.0 kg. When caring for the baby, which of the following is the most appropriate action of the nurse?
  1. Maintaining the child on NPO
  2. Provide frequent feedings with formula
  3. Administration of insulin through the subcutaneous route, as ordered
  4. Assessment of the child’s stool and urine output
Explanation
Answer: B - During the first 24 hours of life, the child may develop severe hypoglycemia caused by high insulin production by the neonate with abrupt decline of maternal glucose. The immediate action of the nurse is to provide early formula feedings, as they can prevent hypoglycemia. Administration of insulin causes further hypoglycemia. Although assessment of the stool and urine output are important, giving early feedings is the priority.
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