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A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take?
- 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. In this scenario, the newborn's blood glucose level is 65 mg/dL, which is considered low. Given that the mother has Type 2 diabetes, the baby is at risk for hypoglycemia due to maternal hyperglycemia during pregnancy. Feeding the newborn immediately will help increase their blood glucose levels. IV dextrose solution administration (choice A) is not necessary at this time as the baby can be orally fed. Obtaining a blood sample for serum glucose level (choice B) can be done later after feeding to confirm improvement. Reassessing blood glucose prior to the next feeding (choice C) delays necessary intervention. The baby must be fed promptly to prevent further hypoglycemia.
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A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg / DL
- B. Hematocrit 48%
- C. Platelets 100,000/ mm 3
- D. Hemoglobin 16 G / DL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm3. This finding is abnormal in a newborn and could indicate a potential bleeding disorder or thrombocytopenia, which requires immediate attention from the provider to assess and manage appropriately. Choice A (Blood glucose 58 mg/dL) is within normal range for a newborn. Choice B (Hematocrit 48%) and D (Hemoglobin 16 g/dL) are also within normal limits for a newborn and do not require immediate reporting.
A client who is 16 weeks of gestation asks the nurse how to prepare her father to a younger sibling. Statements should the nurse make?
- A. You should hold your newborn in your arms when you introduce him to your toddler
- B. You should give your toddler a gift from the baby when she visits
- C. You should move your toddler out of her crib 2 weeks prior to your due date
- D. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
Correct Answer: B
Rationale: Correct Answer: B - You should give your toddler a gift from the baby when she visits.
Rationale: Giving a gift from the baby to the toddler helps create a positive association and bond between the siblings from the beginning. It can also help the toddler feel special and included in the new family dynamic. This gesture can promote a sense of love and acceptance, easing the transition for both the toddler and the newborn.
Incorrect Choices:
A: Holding the newborn when introducing to the toddler may cause the toddler to feel overwhelmed or jealous.
C: Moving the toddler out of her crib close to the due date may disrupt her routine and lead to feelings of insecurity.
D: Placing the toddler in timeout for regressive behavior can create negative associations with the new sibling and cause emotional distress.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
- A. Apply a thin layer lotion to the newborn skin every 8 hours
- B. Trust in you born in a thin layer 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. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage. Choice A is incorrect as lotion can intensify the effects of phototherapy. Choice B is incorrect as the newborn should be undressed to maximize skin exposure. Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
- A. Indirect Coombs test
- B. Liver enzymes
- C. Uric acid level
- D. Serum medication level
Correct Answer: D
Rationale: The correct answer is D: Serum medication level. The nurse should review this value during tocolytic therapy with magnesium sulfate because it is crucial to monitor the therapeutic range of magnesium to prevent toxicity. Monitoring serum levels helps ensure the medication is effective yet safe for the client and the baby.
A: Indirect Coombs test is used to detect antibodies on the surface of red blood cells, not relevant in this scenario.
B: Liver enzymes may be affected by magnesium sulfate but are not directly related to monitoring the medication's therapeutic effect.
C: Uric acid level is not typically monitored during tocolytic therapy with magnesium sulfate.
E, F, G: Irrelevant options.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to work harder to filter and remove excess sugar from the blood. This results in increased urination (polyuria) as the body tries to eliminate the excess glucose through urine. Double vision (A) is more indicative of neurological issues, sweating (C) can be due to various reasons such as anxiety or hormonal changes, and dizziness (D) may be related to blood pressure changes or inner ear problems. Therefore, increased urination is the most specific clinical finding associated with hyperglycemia in gestational diabetes mellitus.