Nokea
A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.
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A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
What is the initial action for a mother experiencing severe vaginal bleeding during labor?
- A. Monitor vital signs and provide IV fluids
- B. Position the mother on her left side
- C. Administer oxygen at 10L/min via mask
- D. Prepare for an immediate cesarean section
Correct Answer: C
Rationale: Administering oxygen improves maternal and fetal oxygenation during significant bleeding.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.