Nokea
The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which action should be taken by the nurse?
- A. Have the mother breastfeed her newborn now.
- B. Immediately feed the infant water with 10% dextrose.
- C. Report the results immediately to the health care provider.
- D. Document the information in the newborn’s medical record.
Correct Answer: D
Rationale: Normal blood sugar values for a full-term newborn are 45–65 mg/dL. A value of 48 mg/dL is normal so the only action required is documentation. Feeding or reporting is unnecessary.
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While preparing parents of a 2-day-old,bottle-feeding newborn for discharge the nurse recognizes the parents’ need for additional teaching about formula feeding. Which statement prompted the nurse’s conclusion?
- A. “We plan to clean our baby’s bottles in the dishwasher.”
- B. “Placing the formula in a bowl of warm water will warm it.”
- C. “We will put the bottle of unfinished formula in the refrigerator.”
- D. “Using our city tap water to mix the powdered formula is safe.”
Correct Answer: C
Rationale: Unfinished formula mixed with saliva should be discarded due to bacterial growth risk. Dishwasher cleaning warming in water and municipal tap water use are safe.
Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?
- A. Is there any possibility that you're pregnant?
- B. Have you eaten anything in the past 24 hours?
- C. Have you taken any medications in the past 24 hours?
- D. Are you allergic to iodine or shellfish?
Correct Answer: A
Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.
The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.
If the parents report all the following history findings to the nurse, which one is most closely correlated with an increased risk of rheumatic fever?
- A. The child was exposed to measles within the past 4 weeks.
- B. The child had a severe sore throat within the past 2 weeks.
- C. The child is lethargic and no longer interested in schoolwork.
- D. The child received a bump on the head while playing.
Correct Answer: B
Rationale: Rheumatic fever is strongly associated with a recent streptococcal infection, such as a sore throat caused by group A Streptococcus. A severe sore throat within the past 2 weeks is a key risk factor, as it may indicate an untreated or inadequately treated streptococcal infection.
The nurse has provided the mother with information about her newborn’s milia. The nurse evaluates that the mother understands information when the mother makes which statement?
- A. “I will put lotion on my infant’s nose in the morning and at night.”
- B. “I understand these raised white spots will clear up without treatment.”
- C. “I realize the baby will need surgery to remove these skin lesions.”
- D. “I will apply alcohol twice a day to the lesions until they disappear.”
Correct Answer: B
Rationale: Milia are benign self-resolving white spots from sebaceous glands clearing within a month. Lotion surgery or alcohol are inappropriate.