A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe

Supplement feedings with dextrose water

Administer intravenous dextrose

Obtain a total serum bilirubin

Encourage breastfeeding every 2 hr

Prepare for an exchange transfusion

Obtain blood cultures

Answer and Explanation

Correct Answer : C,D

A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.

B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.

C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.

D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.

E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.

F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.

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Correct Answer is A

Explanation

A. Changing a perineal pad only every 4 hours may indicate excessive bleeding or hemorrhage, which requires immediate assessment.
B. A urine output of 750 mL in 6 hours is within normal limits (about 125 mL/hr).
C. 1+ deep tendon reflexes indicate decreased reflexes, which is expected during magnesium sulfate therapy and generally not an immediate concern.
D. Abdominal cramping during breastfeeding is common due to uterine contractions and is usually not urgent.

A. Water retention B. Tachycardia C. Seizures D. Hypertension

Correct Answer is D

Explanation

A. Water retention is not a common adverse effect of methylergonovine.
B. Tachycardia is not typically caused by methylergonovine; bradycardia or hypertension is more common.
C. Seizures are not a common side effect of this medication.
D. Hypertension is a known adverse effect of methylergonovine and requires close monitoring, especially in clients with preexisting hypertension.

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A nurse is caring for the newborn 1 day after birth Exhibits Select 2 orders which the nurse should anticipate that the provider will prescribe

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct Answer is D

Explanation

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A nurse is caring for a newborn Exhibits Which of the following statements should the nurse include in the plan of care for the baby

A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe