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Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?
- A. Swaddle the infant in a warm blanket.
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Document the findings in the record.
Correct Answer: B
Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.
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The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump?
- A. 12 mL/hour
- B. 2 mL/hour
- C. 22 mL/hour
- D. 42 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate in mL/hour, first, convert 2 milliunits/minute to milliunits/hour by multiplying by 60 to get 120 milliunits/hour. Then, calculate the mL/hour using the formula: milliunits/hour (120) total volume (1000 mL) · units in IV solution (10 units) = 1200 mL/hour. Therefore, the nurse should program the infusion pump to deliver 12 mL/hour to provide the prescribed dose of oxytocin. Choice B is incorrect as it does not reflect the correct calculation. Choice C is incorrect as it is not derived from the correct formula. Choice D is incorrect as it is not the result of the accurate calculation based on the provided information.
The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
- A. A gravida 6, para 5 who is 38 years of age and in early labor.
- B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
- C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
- D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
Correct Answer: D
Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus.
Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.
The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?
- A. Prevent hemorrhagic disorders.
- B. Help an immature liver.
- C. Improve insufficient dietary intake.
- D. Stimulate the immune system.
Correct Answer: A
Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.
The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?
- A. Hemoglobin A1C.
- B. Postprandial blood glucose test.
- C. Oral glucose tolerance test.
- D. Fasting blood glucose.
Correct Answer: C
Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.
In planning care for a client at 30-weeks gestation experiencing preterm labor, what maternal prescription is most important in preventing this fetus from developing respiratory syndrome?
- A. Betamethasone (Celestone) 12mg deep IM.
- B. Butorphanol 1mg IV push q2h PRN pain.
- C. Ampicillin 1g IV push q8h.
- D. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.
Correct Answer: A
Rationale: The administration of Betamethasone (Celestone) is crucial in cases of preterm labor to promote fetal lung maturation and reduce the risk of respiratory distress syndrome in the newborn. Betamethasone helps enhance the production of surfactant in the fetal lungs, improving their functionality and decreasing the likelihood of respiratory complications upon birth. Butorphanol is an analgesic and not indicated for preventing respiratory syndrome in preterm infants. Ampicillin is an antibiotic used for infection prevention and treatment, not for fetal lung maturation. Terbutaline is a tocolytic agent used to inhibit contractions, but it does not have a direct effect on fetal lung maturity.