Level: Advanced
Difficulty: Hard
Subtopic: Breastfeeding support
NCLEX: A postpartum client on the mother-baby unit is being evaluated for breastfeeding initiation. The nurse reviews th…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for breastfeeding initiation. The nurse reviews this trend: newborn glucose values are 42, 38, and 35 mg/dL with jitteriness. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.