Nokea
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply post-birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating the need for prompt intervention to prevent further complications. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are small red or purple spots on the skin caused by bleeding under the skin and are not directly related to hypoglycemia. Increased muscle tone (C) is not a typical sign of hypoglycemia in newborns.
You may also like to solve these questions
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: The correct answer is B, D . Abdominal pain (A) is not specific to any of the given conditions. Diabetes (C) is not directly related to the assessment findings provided. Absence of condom (E) is not an assessment finding, but a behavior. Trichomoniasis is characterized by greenish discharge, and pain on urination can be a symptom of both gonorrhea and trichomoniasis.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and closure. It acknowledges the baby's existence and validates the client's experience. Choice A may be incorrect as it could deprive the client of the opportunity to spend time with their baby for closure. Choice C is incorrect as it may not be necessary in all cases and could be overwhelming for the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Correct Answer: B: Assess for grasp reflex in the affected extremity.
Rationale:
- Assessing for grasp reflex is indicated to evaluate neurologic function and muscle tone in the affected arm.
- This helps in determining the extent of impairment and guiding further interventions.
- Range of motion exercises (A) may worsen the condition if performed too early.
- Immobilizing the arm (C) may lead to joint stiffness and muscle atrophy.
- Limiting physical handling (D) may hinder bonding and infant's development.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct response is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically done to assess genetic abnormalities, not to determine the sex of the fetus. Amniocentesis involves obtaining a sample of amniotic fluid to analyze the fetal cells for chromosomal abnormalities like Down syndrome. The procedure is not primarily used for determining the sex of the baby. The other options are incorrect for various reasons: A is inaccurate as there is no age requirement for amniocentesis; C is incorrect as chorionic villus sampling is another prenatal diagnostic test, not typically used to determine fetal sex; and D is inappropriate as scheduling a medical procedure without further assessment is not recommended.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.