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A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider?
- A. Hgb 20 g/dL
- B. Bilirubin 2mg/dL
- C. Platelets 200 .000/mm3
- D. WBC count 32.000/mm3
Correct Answer: D
Rationale: The correct answer is D: WBC count 32,000/mm3. A newborn with a WBC count of 32,000/mm3 indicates a potential infection, as newborns typically have a higher WBC count initially due to stress of birth. It is important to report this finding to the provider for further evaluation and possible treatment. Choices A, B, and C are within normal range for a 24-hour-old newborn, so they do not require immediate reporting. Choice D, Hgb 20 g/dL, is not a typical laboratory finding for a newborn and would require further investigation, but it is not as urgent as a high WBC count indicating infection.
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A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
- A. Give terbutaline Subq
- B. Position the client in a knee chest position
- C. Apply oxygen via nonrebreather
- D. Administer a bolus of lactated ringer
Correct Answer: D
Rationale: The correct answer is D: Administer a bolus of lactated Ringer. Maternal hypotension following epidural placement indicates hypovolemia or vasodilation. Providing a bolus of lactated Ringer helps increase intravascular volume, improving blood pressure. Terbutaline Subq (A) is not indicated for hypotension. Positioning the client in a knee-chest position (B) is not appropriate for maternal hypotension. Applying oxygen via non-rebreather (C) may not address the underlying cause of hypotension.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.
A nurse is using Nagele's rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as the client's expected delivery date?
- A. April 21st
- B. April 4th
- C. May 5th
- D. May 21st
Correct Answer: C
Rationale: The correct answer is C: May 5th. Nagele's rule is used to estimate the expected delivery date by adding 7 days to the first day of the last menstrual cycle, subtracting 3 months, and then adding 1 year. In this case, the first day of the last menstrual cycle was July 28th. Adding 7 days gives August 4th. Subtracting 3 months gives May 4th. Adding 1 year gives May 4th of the next year. Since May 4th falls on a Sunday, the expected delivery date is adjusted to the following day, May 5th. Choice A, B, and D are incorrect because they do not follow the correct calculations of Nagele's rule.
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 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.