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A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
- A. Obtain a blood glucose level.
- B. Feed the infant glucose water (10%).
- C. Administer oxygen.
- D. Decrease environmental stimuli.
Correct Answer: A
Rationale: Obtaining a blood glucose level confirms hypoglycemia as the cause of jitteriness, common in LGA infants of diabetic mothers, guiding treatment.
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A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from Neisseria gonorrhoeae, protecting the newborn's eyes from infection.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
History and Physical:
Nurses' Notes:
Vital Signs
The neonate was born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation. The mother had an uncomplicated pregnancy and delivery.
The nurse evaluates the data presented. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Potential Conditions: Altered respiratory function, Hypoglycemia, Thermoregulation, Sepsis, Hyperbilirubinemia
- B. Actions: Provide manual breaths with a bag-valve mask (BVM), Give dextrose solution orally, Administer intravenous (IV) antibiotics, Place the neonate under a radiant warmer, Perform a heel stick for blood glucose testing
- C. Parameters: Respiratory rate, Temperature, Blood glucose levels, Oxygen saturation, Bilirubin levels
Correct Answer: B,E,C
Rationale: Hypoglycemia is likely due to jitteriness and low temperature; oral dextrose and heel stick glucose testing address it, while monitoring glucose levels and temperature tracks progress.