A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Glyburide is an oral hypoglycemic medication used to control blood glucose levels in individuals with type 2 diabetes. It is also used in the management of gestational diabetes mellitus (GDM) when dietary and lifestyle interventions alone are not sufficient to control blood glucose levels. Glyburide works by stimulating the pancreas to release insulin and also by increasing the sensitivity of peripheral tissues to insulin. It is preferred over insulin injections because it is easier to administer and monitor, and it does not pose a risk of hypoglycemia as long as blood glucose levels are closely monitored. In addition, glyburide does not cross the placenta, which minimizes the risk of fetal hypoglycemia. However, some studies have suggested that glyburide may be associated with an increased risk of neonatal hypoglycemia and macrosomia (large birth weight), so careful monitoring of the mother and fetus is required. Other medications such as levothyroxine, nifedipine, and chlorpromazine are not used in the management of gestational diabetes mellitus.
Correct Answer is C
Explanation
A. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
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