A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Inform her that a decreased need for insulin occurs while breastfeeding.
- B. Counsel her to increase her caloric intake.
- C. Advise the client to breastfeed more frequently.
- D. Schedule an appointment for the client with the diabetic nurse educator.
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
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The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences a return to red bleeding after transitioning to pink and white, it may indicate possible complications like hemorrhage or retained placental fragments. Instructing the client to reduce activity level and promptly notify the healthcare provider is crucial for timely evaluation and management of these potentially serious postpartum complications.
A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?
- A. Refer the mother to the Centers for Disease Control and Prevention.
- B. Report the incident to the school principal.
- C. Culture the bite site when the child returns to school.
- D. Schedule a test for Lyme disease if a rash appears.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometry.
- B. Evaluate cord blood Coombs test results.
- C. Review maternal medical records for blood type and Rh factor.
- D. Prepare the newborn for phototherapy.
Correct Answer: A
Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
- A. Advise the mother to wait at least another month before starting any solid foods.
- B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
- C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
- D. Encourage the mother to schedule a developmental assessment of the infant.
Correct Answer: C
Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
- A. 150 mL/hour
- B. 250 mL/hour
- C. 50 mL/hour
- D. 275 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. In this case, with 20 grams of magnesium sulfate in 500 mL of solution, there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. This calculation ensures the correct dose is delivered within the specified time frame.