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 C
Explanation
A: An adolescent with multiple contusions due to a fall that occurred 2 days ago can be managed by the PN as the condition is stable and does not require the advanced skills of an RN.
B: A 75-year-old client with renal calculi who requires urine straining can also be assigned to the PN because urine straining is a task within the PN's scope of practice.
C: A 30-year-old depressed client who admits to suicide ideation requires the expertise of an RN due to the need for continuous assessment, potential for crisis intervention, and the complexity of care needed.
D: A 64-year-old client who had a total hip replacement the previous day would typically be stable post-operation and could be managed by the PN, with the RN available for any complications that may arise.
Correct Answer is ["5.6"]
Explanation
Convert pounds to kg 1kg= 2.2 pounds 132pounds= 132/2.2=60kg
Desired dose per minute= 5 mcg/kg= 560=300mcg/min Desired dose per hour= 300mcg60mins= 18000mcg Available dose= 1600mg/500ml
1mg=1000mcg
Available dose = 1600000mcg/500ml Infusion rate:
1600000mcg=500ml 18000mcg=18000500/1600000
= 5.625 mL/hour
Rounded to the nearest tenth:5.6 ml/hour
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