Patient data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Obtain postoperative vital signs: This task is within the scope of practice for a practical nurse (PN) as it involves monitoring and recording the vital signs of a client post-surgery, which is a fundamental nursing skill.
B. Start the second blood transfusion: This task is typically reserved for a registered nurse (RN) due to the complexity and potential complications associated with blood transfusions.
C. Initiate PCA pumps: The initiation of PCA pumps is generally a responsibility of the RN because it requires assessment and understanding of the medication dosage and patient pain management needs.
D. Perform daily surgical dressing change: This is an appropriate task for a PN as it involves wound care and monitoring for signs of infection, which are within the PN's capabilities.
E. Administer a dose of insulin per sliding scale: Administering medications, including insulin, is a task that can be delegated to a PN, provided they have the knowledge and skills to do so safely.
Correct Answer is B
Explanation
A. Explaining that the dosage has been changed is not appropriate without verifying the correct dosage first.
B. Withholding the medication until the dosage can be confirmed is the safest approach to prevent potential medication errors.
C. Informing the client that he may refuse the medication is an option, but it does not address the potential discrepancy in dosage.
D. Telling him to take the medication and then verifying the dosage at the next healthcare team meeting could result in a medication error and is not a safe practice
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