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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 providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy. This of the following statements by the client indicates an understanding of the teaching.
- A. “I will count baby’s lacks every other day.
- B. “I will alternate the arm use to check my blood pressure
- C. I will check my urine for protein daily
- D. I will consume 50 grams of protein daily
Correct Answer: C
Rationale: The correct answer is C: "I will check my urine for protein daily." This is the correct answer because monitoring urine for protein is crucial in managing preeclampsia. Proteinuria is a key marker for worsening preeclampsia as it indicates kidney damage. By checking urine daily, the client can detect early signs of deterioration and seek medical help promptly.
Answers A, B, and D are incorrect because they do not directly relate to monitoring preeclampsia. Counting baby's kicks (A) and alternating arm use for blood pressure checks (B) are important but not as critical as monitoring proteinuria. Consuming 50 grams of protein daily (D) is beneficial for overall health during pregnancy but does not specifically address the management of preeclampsia.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct Answer: A
Rationale: The correct answer is A, as it encourages the client to make decisions based on their preferences. By stating, "You can bathe and dress your baby if you’d like to," the nurse offers support and control to the client during a difficult time. This empowers the client to engage in meaningful rituals and take control of the situation.
Choice B is incorrect because it imposes guilt on the client by suggesting that not holding the baby will make letting go harder, which may not be the case for everyone. Choice C is incorrect as naming the baby should be a personal decision and not a directive from the nurse. Choice D is incorrect because it assumes the client's readiness for another baby, which may not be the case and can be insensitive.
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.
A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Negele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
- A. December 15
- B. October 30
- C. January 15
- D. Nov 30
Correct Answer: A
Rationale: To calculate the estimated due date using Negele's rule, we add 7 days to the first day of the last menstrual period, subtract 3 months, and then add a year. March 8 + 7 days = March 15. Subtracting 3 months gives us December 15. Adding a year gives the estimated due date as December 15. This is the correct answer as it follows the standard calculation method. Other choices are incorrect as they do not follow the correct formula or have errors in calculation.