Nokea
What is the nurse's first action for a newborn showing signs of hypoglycemia?
- A. Feed the newborn formula immediately
- B. Encourage breastfeeding or formula feeding
- C. Monitor glucose levels every hour
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.
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A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?
- A. "My plan is to visit the outpatient clinic daily for treatment."
- B. "will see my health care provider at least every 2 weeks."
- C. "My baby will not have to go through withdrawal when I take methadone."
- D. "With oral methadone, my baby and I are at decreased risk of infection."
Correct Answer: B
Rationale: The correct answer is B because seeing the healthcare provider every 2 weeks may not be frequent enough for monitoring a pregnant patient with a heroin habit. Regular monitoring is crucial for the well-being of both the mother and the baby. Option A shows a proactive approach for daily treatment, Option C is incorrect as methadone does not eliminate the risk of withdrawal in newborns, and Option D is incorrect as methadone does not reduce the risk of infection. Regular and close monitoring is essential in such cases to ensure the safety and health of both the mother and the baby.
The nurse provides education regarding male sterilization. What important information is provided?
- A. “Many people have vasectomies reversed.â€
- B. “You will need to return to the office to check for sperm in your ejaculate.â€
- C. “You will be sterile after 3 months.â€
- D. “Vasectomy consent forms must have both partners’ consent.â€
Correct Answer: B
Rationale: The correct answer is B: "You will need to return to the office to check for sperm in your ejaculate." This information is crucial as it ensures the success of the sterilization procedure. By checking for sperm in the ejaculate, the effectiveness of the vasectomy can be confirmed. This step is important to ensure that the individual is indeed sterile and can rely on the procedure for contraception.
Choice A is incorrect because vasectomy reversal is not always successful and should not be assumed. Choice C is incorrect as sterility is not immediate and may take several months after the procedure. Choice D is incorrect as consent forms for vasectomy typically require only the individual undergoing the procedure to give consent.
In summary, choice B is correct because it emphasizes the need for follow-up to confirm sterility, while the other choices provide incorrect or irrelevant information regarding male sterilization.
A client at 38 weeks' gestation is admitted for decreased fetal movement. What diagnostic test should the nurse anticipate?
- A. Amniocentesis.
- B. Biophysical profile (BPP).
- C. Contraction stress test.
- D. Maternal serum alpha-fetoprotein (MSAFP).
Correct Answer: B
Rationale: The correct answer is B: Biophysical profile (BPP). At 38 weeks' gestation with decreased fetal movement, BPP is used to assess fetal well-being by evaluating fetal heart rate, fetal movements, fetal tone, amniotic fluid volume, and sometimes placental function. It provides immediate information on fetal status and is non-invasive. Amniocentesis (A) is not indicated for decreased fetal movement. Contraction stress test (C) is contraindicated due to the risk of inducing contractions in a term pregnancy. Maternal serum alpha-fetoprotein (D) is a screening test for neural tube defects and is not relevant in this situation.
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.
The nurse understands vitamin k is for?
- A. Not initially synthesized because of sterile bowel at birth (so they don't have enough clothing factors)
- B. Necessary for the production of platelets
- C. Important for production red blood cells
- D. Responsible for the breakdown of bilirubin and the prevention of jaundice
Correct Answer: D
Rationale: The correct answer is D because vitamin K is responsible for the breakdown of bilirubin in the liver, which helps prevent jaundice in newborns. Bilirubin is a product of the breakdown of old red blood cells, and vitamin K plays a crucial role in this process. Choice A is incorrect as sterile bowel does not affect vitamin K synthesis. Choice B is incorrect because platelet production is not directly related to vitamin K. Choice C is incorrect as red blood cell production is mainly regulated by other nutrients like iron, vitamin B12, and folate, not vitamin K.