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The nurse is assessing a client with suspected gestational diabetes. What is the most reliable diagnostic test?
- A. Random blood glucose test.
- B. Oral glucose tolerance test (OGTT).
- C. Fasting blood glucose test.
- D. Hemoglobin A1C.
Correct Answer: B
Rationale: The oral glucose tolerance test (OGTT) is the standard for diagnosing gestational diabetes.
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The nurse is caring for a client with gestational diabetes. What fetal complication should the nurse monitor for after birth?
- A. Hyperglycemia.
- B. Macrosomia.
- C. Hypoglycemia.
- D. Hyperbilirubinemia.
Correct Answer: C
Rationale: Newborns of mothers with gestational diabetes are at risk for hypoglycemia due to high insulin levels after birth.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs.
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.
The nurse is teaching a client with a midline episiotomy about perineal care after vaginal birth. Which statement from the client indicates she
- B. I will use the perineal bottle without touching perineum each time going to the bathroom
- C. I will gently pat perineal dry rather than wipe
- D. I will only use the perineal bottle after bowel movements
Correct Answer: C
Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.
What does the nursing process describe?
- A. what nurses do
- B. how nurses think
- C. where nurses provide care
- D. who nurses care for
Correct Answer: B
Rationale: The nursing process describes how nurses think and approach patient care. It is a systematic problem-solving approach that nurses use to provide individualized patient care. The nursing process consists of five main steps: assessment, diagnosis, planning, implementation, and evaluation. Through this process, nurses gather information, identify patient problems, set goals, implement interventions, and evaluate outcomes. By following the nursing process, nurses can deliver holistic and effective care to their patients.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
- A. Administer nitric oxide inhalation therapy to the newborn
- B. Insert an orogastric decompression tube with low wall suction.
- C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
- D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
Correct Answer: D
Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.