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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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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.
A newborn is born to a mother with gestational diabetes. What complication is the nurse most likely to monitor for?
- A. Hypoglycemia
- B. Hyperthermia
- C. Jaundice
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Babies of diabetic mothers risk hypoglycemia due to high insulin.
the nurse knows that management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides are for a client with this condition should be aware that which of the following is the optimal pharmacological therapy for pain relief dysmenorrhea? Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a client with this condition should be aware that the optimal pharmacologic therapy for pain relief is:
- A. Acetaminophen.
- B. Oral contraceptives (OCPs). c.Nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Aspirin
- D. ampicillin
Correct Answer: C
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the optimal pharmacological therapy for pain relief in primary dysmenorrhea. They work by reducing the production of prostaglandins, which are responsible for causing uterine contractions and pain. NSAIDs such as ibuprofen, naproxen, and mefenamic acid are commonly used to alleviate menstrual cramps. Acetaminophen may also provide pain relief, but it does not have the anti-inflammatory properties of NSAIDs. Oral contraceptives (OCPs) can help regulate menstrual cycles and reduce pain in some individuals, but they are not the first line of treatment for immediate pain relief in primary dysmenorrhea. Aspirin, while an NSAID, is not typically recommended for menstrual pain relief due to its potential side effects on blood clotting and gastrointestinal irritation.
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
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.