A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Confirm the newborn's Apgar score

Verify the newborn's identification.

Administer vitamin K to the newborn.

Determine obstetrical risk factors.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.

Choice B Reason:

Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.

Choice C Reason:

Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.

Choice D Reason:

Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.

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Correct Answer is A

Explanation

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." C. "I will continue taking my insulin if I experience nausea and vomiting D. "I will ensure that my bedtime snack is high in refined sugar."

Correct Answer is C

Explanation

Choice A Reason:

"I should have a goal of maintaining my fasting blood glucose between 100 and 120." This statement does not indicate understanding of the teaching. Recommended target for fasting blood glucose levels during pregnancy in women with diabetes is typically lower, often between 60 and 90 mg/dL.

Choice B Reason:

"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." This statement does not indicate understanding of the teaching . Exercising when blood glucose is already elevated to 250 or greater may not be safe. Exercise is generally recommended to help manage blood glucose levels, but the specific approach and timing should be discussed with the healthcare provider.

Choice C Reason:

"I will continue taking my insulin if I experience nausea and vomiting." This statement reflects an awareness of the importance of continuing insulin administration even if the client is experiencing nausea and vomiting. Consistent insulin management is crucial for maintaining blood glucose levels within the target range during pregnancy.

Choice D Reason:

"I will ensure that my bedtime snack is high in refined sugar." This statement does not indicate understanding of the teaching. Bedtime snacks should focus on providing sustained energy and stabilizing blood glucose levels. A snack high in refined sugar is not recommended as it can lead to fluctuations in blood glucose levels.

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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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