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Patient data

Exhibits

The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities

Which 6 orders take priority?

Transfer to NICU

Keep in warmer with bilirubin lights

Bolus of 2 ml/kg glucose 10% IV

Blood glucose level

Contact Respiratory Therapy for ABG and oxygen therapy

Feed immediately

Apply dextrose (sugar) gel inside the baby's cheek

Echocardiogram

Monitor for respiratory distress

Monitor temperature every 30 minutes

Answer and Explanation

Correct Answer : C,D,E,F,I,J

A. Transfer to NICU - While NICU care is important, immediate stabilization takes precedence.

B. Keep in warmer with bilirubin lights - This is important for thermoregulation and managing jaundice but is not the most immediate concern.

C. Bolus of 2 ml/kg glucose 10% IV - This is critical to address the hypoglycemia (blood glucose 35 mg/dl).

D. Blood glucose level - Monitoring is essential for ongoing assessment of hypoglycemia.

E. Contact Respiratory Therapy for ABG and oxygen therapy - Given the high respiratory rate and potential for respiratory distress, this is a priority.

F. Feed immediately - Feeding can help stabilize blood glucose levels.

G. Apply dextrose (sugar) gel inside the baby's cheek - This is an alternative to IV glucose but less immediate than a bolus.

H. Echocardiogram - Important for cardiac assessment but not an immediate priority.

I. Monitor for respiratory distress - Essential due to the high respiratory rate and risk of complications from maternal diabetes.

J. Monitor temperature every 30 minutes - Important for detecting hypothermia due to the low axillary temperature.

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Correct Answer is C

Explanation

A. Measuring abdominal girth is not specific to suprapubic catheter care. While it may be relevant in certain situations, it does not directly assess the condition of the catheter or its insertion site.

B. Assessing the perineal area is important, but the primary focus for a client with a suprapubic catheter should be on the insertion site itself, as this is where complications such as infection or leakage are most likely to occur.

C. Assessing the insertion site is essential to monitor for any signs of infection, inflammation, or other complications related to the catheter. This assessment helps ensure the catheter is functioning correctly and that no adverse effects are developing.

D. Palpating the flank area is generally not a routine assessment for a client with a suprapubic catheter unless there are specific concerns about kidney function or pain in that area.

A. Notify the healthcare provider. B. Prepare a continuous heparin infusion per protocol. C. Provide supplemental oxygen. D. Bring the emergency crash cart to the bedside.

Correct Answer is C

Explanation

A. While notifying the healthcare provider is important, the priority is to address the client's immediate physiological needs.
B. Starting a continuous heparin infusion is important in the management of a pulmonary embolus, but providing oxygen is the first priority to ensure adequate oxygenation.

C. Providing supplemental oxygen helps alleviate hypoxia, which is critical in the management of a pulmonary embolus.
D. Bringing the emergency crash cart may be necessary if the client's condition deteriorates, but providing oxygen takes precedence in the initial management.

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Patient data Exhibits The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities Which 6 orders take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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Patient data

Exhibits

The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities

Which 6 orders take priority?