A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.

Exhibits

Which of the following actions should the nurse take

Diagnostic results

Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL

Platelet count 50,000 mm

WBC count 4,000 mm3

Answer and Explanation

The Correct Answer is A

The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the

abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.

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Correct Answer is D

Explanation

A. An HbA1C level of 6% is within the target range for a pregnant woman with type 1 diabetes, indicating good glycemic control. Therefore, it does not need to be reported to the provider.
B. Platelet levels of 170,000/mm³ fall within the normal range (150,000–450,000/mm³) and do not indicate a need for concern.
C. A hematocrit (Hct) of 34% is slightly low, but mild anemia is common during pregnancy due to increased plasma volume. This level does not usually require immediate intervention.
D. A blood urea nitrogen (BUN) level of 25 mg/dL is elevated (normal range 7–20 mg/dL) and may indicate renal impairment, which is a concern in a pregnant client with type 1 diabetes. This finding should be reported to the provider as it can signal potential kidney issues that need to be addressed.

A. Administer misoprostol 25 mcg vaginally. B. Decrease maintenance IV solution infusion rate. C. Administer oxygen via face mask at 2 L/min. D. Place the client in a lateral position.

Correct Answer is D

Explanation

The correct answer is choice D: Place the client in a lateral position. Late decelerations of the fetal heart rate on the monitor tracing can indicate fetal distress, which is a potential complication of oxytocin induction of labor. Placing the client in a lateral position can improve uteroplacental blood flow and may improve fetal oxygenation.

Choice A, administering misoprostol 25 mcg vaginally, can increase uterine contractions and may further compromise fetal oxygenation. Choice B, decreasing maintenance IV solution infusion rate, and choice C, administering oxygen via face mask at 2 L/min, are not effective interventions for late decelerations of the fetal heart rate.

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A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Exhibits Which of the following actions should the nurse take

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.

Exhibits

Which of the following actions should the nurse take