Nokea
When caring for a newborn with macrosomia born to a mother with diabetes mellitus, which newborn complication should the nurse prioritize care for?
- A. Hypoglycemia
- B. Hypomagnesemia
- C. Hyperbilirubinemia
- D. Hypocalcemia
Correct Answer: A
Rationale: In newborns of diabetic mothers with macrosomia, hypoglycemia is the priority focus of care due to the risk of developing low blood sugar levels after birth. Infants born to diabetic mothers are at risk of hypoglycemia because they have been exposed to high glucose levels in utero and produce high levels of insulin. Hypoglycemia can lead to serious complications if not promptly identified and managed, making it crucial for nurses to closely monitor blood glucose levels and provide necessary interventions to prevent adverse outcomes.
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A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?
- A. Validate the client's feelings by saying, 'It sounds like you are feeling sad that things didn't go as planned.'
- B. Assure the client by stating, 'At least you know you have a healthy baby.'
- C. Encourage the client by suggesting, 'Maybe next time you can have a vaginal delivery.'
- D. Provide information by saying, 'You can resume sexual relations sooner than if you had delivered vaginally.'
Correct Answer: A
Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.
A newborn's mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?
- A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months
- B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen
- C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth
- D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days
Correct Answer: C
Rationale: In the scenario where a newborn's mother is positive for hepatitis B surface antigen, the infant should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. This is crucial to provide passive and active immunity against the Hepatitis B virus. Hepatitis B immune globulin provides immediate protection by giving passive immunity, while the vaccine stimulates active immunity in the infant. Administering both within 12 hours of birth is important to prevent vertical transmission of the virus.
A client with severe preeclampsia is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe to continue the infusion?
- A. Diminished deep-tendon reflexes
- B. Respiratory rate of 16/min
- C. Urine output of 50 mL in 4 hours
- D. Heart rate of 56/min
Correct Answer: B
Rationale: A respiratory rate of 16/min within the normal range is an essential parameter to monitor when administering magnesium sulfate, as respiratory depression is a potential adverse effect. Diminished deep-tendon reflexes may indicate magnesium toxicity, warranting immediate intervention. A urine output of 50 mL in 4 hours is below the expected amount, suggesting decreased kidney perfusion, which can be exacerbated by magnesium sulfate. A heart rate of 56/min is bradycardic and may indicate magnesium toxicity, requiring assessment and possible discontinuation of the infusion.
A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
- A. Recheck the client's temperature in 4 hours
- B. Administer glucocorticoids intramuscularly
- C. Assess the odor of the amniotic fluid
- D. Prepare the client for emergency cesarean section
Correct Answer: C
Rationale: In a pregnant woman with a temperature of 38.9°C (102°F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.
A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
- A. Administer oxygen via nasal cannula
- B. Offer option to view products of conception
- C. Instruct the client to increase potassium-rich foods in the diet
- D. Maintain the client on bed rest
Correct Answer: B
Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.