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A nurse is caring for a newborn boy, 6 hours old, whose bedside glucose meter reading is 65 mg/dL. The newborn's mother has Type 2 diabetes mellitus.
- A. Administer 50 mL of dextrose solution IV
- B. Obtain a blood sample of serum glucose level
- C. Reassess the blood glucose level prior to the next feeding
- D. Feed the newborn immediately
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. By feeding the newborn, the nurse can stimulate the release of insulin, which will help regulate the baby's blood sugar levels. This is important especially in the case of a newborn born to a mother with Type 2 diabetes mellitus, as the baby may be at risk for hypoglycemia. Administering IV dextrose solution (choice A) is not necessary at this point as feeding is the initial intervention. Obtaining a blood sample for serum glucose level (choice B) can be done later but immediate feeding takes precedence. Reassessing blood glucose prior to the next feeding (choice C) may delay necessary intervention.
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A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr
- B. Creatinine 0.8 mg/ dL
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet Count 60,000/mm3. In preeclampsia, low platelet count can indicate thrombocytopenia, a serious complication that can lead to bleeding. This finding requires immediate attention to prevent severe complications like hemorrhage or organ damage.
A: Urine protein concentration within normal range for preeclampsia.
B: Creatinine within normal range, not a priority in this scenario.
C: Hemoglobin within normal range, not a priority in this scenario.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used for infertility, and a common side effect is breast tenderness due to its estrogen-like effects on the body. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate. Tinnitus could be related to ototoxic medications, urinary frequency could be due to diuretics, and chills could be due to infections or allergic reactions, but they are not commonly linked to clomiphene citrate. Therefore, the nurse should focus on educating the client about the potential adverse effect of breast tenderness when taking clomiphene citrate.
A nurse is reviewing the laboratory results for a newborn 12 hours old. Which of the following is an expected findings.
- A. Glucose 40mg/dl
- B. WBC 6000
- C. Hemoglobin 12
- D. Platelets 80000
Correct Answer: A
Rationale: The correct answer is A: Glucose 40mg/dl. In newborns, normal glucose levels range from 40-60mg/dl. This level is expected to be lower in the immediate postnatal period due to the transition from placental to independent glucose regulation. WBC count of 6000 is within normal range. Hemoglobin at 12 is normal for a newborn. Platelets of 80000 are low and could indicate a potential issue, such as thrombocytopenia, which would require further investigation.
A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.