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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: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.
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A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1-hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1-hour glucose tolerance test. At 24 weeks, it is important to screen for gestational diabetes. This test helps assess the body's ability to metabolize glucose. The other choices are not typically done at the 24-week appointment. B: Rubella titer is usually done earlier in pregnancy to check immunity. C: Group B strep culture is usually done around 35-37 weeks. D: Blood type and Rh are usually checked at the first prenatal visit.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium – start fluid
- B. placenta previa
- C. Midline episiotomy
- D. Prolonged labor
Correct Answer: C
Rationale: The correct answer is C: Midline episiotomy. Midline episiotomies are associated with a higher risk of infection due to the location being close to the anal canal, which harbors bacteria. The incision can become contaminated during bowel movements or urination, increasing the risk of infection. Placenta previa (B) is a condition related to the positioning of the placenta, not directly associated with infection risk. Meconium-stained amniotic fluid (A) may indicate fetal distress but does not directly increase the mother's risk of infection. Prolonged labor (D) can lead to increased risk of infection due to prolonged exposure to vaginal flora, but it is not as direct a risk factor as a midline episiotomy.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring indicates respiratory distress, which is a priority concern in newborns as it can lead to hypoxia. The nurse should assess this newborn first to ensure adequate oxygenation.
B: Subconjunctival hemorrhage is common and not an urgent issue.
C: Overlapping suture lines are normal in newborns and do not require immediate attention.
D: Not passing rust-stained urine could indicate a metabolic issue but is not as urgent as respiratory distress.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.
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.