A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
Obtain a blood glucose level.
Feed the infant glucose water (10%).
Administer oxygen.
Decrease environmental stimuli.
The Correct Answer is A
Choice A rationale
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Epidural placement requires assessing the current cervical dilation and fetal station. Without this information, premature epidural placement can impede labor progress or mask signs of complications.
Choice B rationale
A bolus of intravenous fluids is necessary before epidural anesthesia to prevent hypotension. However, assessing cervical dilation first ensures that it is appropriate to proceed with pain management.
Choice C rationale
Decreasing the oxytocin infusion rate is not the initial priority. The current cervical dilation and effacement need to be assessed to determine the appropriate management of labor and pain control.
Choice D rationale
Determining current cervical dilation is the first action to evaluate labor progress and make informed decisions regarding pain management and epidural placement, ensuring safe and effective care.
Correct Answer is ["36"]
Explanation
Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.
Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.
Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.
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