Nokea
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- A. Hypoglycemic, small for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, large for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age and at risk for hypoglycemia due to maternal glucose levels.
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The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client's right to emergency services, regardless of ability to pay, is provided by which piece of legislation?
- A. HIPAA
- B. the Continuity of Care Act
- C. the Patient's Bill of Rights
- D. the Code of Ethics for Nurses
Correct Answer: D
Rationale: The Emergency Medical Treatment and Active Labor Act (EMTALA) ensures that emergency services are provided regardless of ability to pay, not the options listed.
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- A. Prepare the client for a caesarean section
- B. Apply the fetal heart monitor
- C. Place the client in the Trendelenburg position
- D. Perform an ultrasound exam
Correct Answer: B
Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale:
A client is to receive 1,000 mL of potassium chloride in 5% dextrose injection (D5W) intravenously over 3 hours and 20 minutes using a drop factor of 15 drops/mL. What is the required flow rate (drops) per minute? Record your answer using a whole number.
Correct Answer: 75
Rationale: To calculate the flow rate in drops per minute, use the formula: (Total volume X Drop factor)/ Total time in minutes. The total volume is 1,000 mL, the drop factor is 15 drops/mL, and the time is 3 hours 20 minutes = 200 minutes. Thus, (1,000 X 15)/ 200 = 15,000/ 200 = 75 drops/minute.
The mother of a male child with cystic fibrosis tells the nurse that she hopes her son's children won't have the disease. The nurse is aware that:
- A. There is a 25% chance that his children will have cystic fibrosis.
- B. Most of the males with cystic fibrosis are sterile.
- C. There is a 50% chance that his children will be carriers.
- D. Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Correct Answer: B
Rationale: Most males with cystic fibrosis are sterile due to congenital absence of the vas deferens, significantly reducing the likelihood of having biological children.