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 ["45"]
Explanation
1mg=1000mcg
4mg= 41000= 4000mcg
Desired dose= 3mcg/min
Desired dose per hour=3mcg60= 180mcg Form the prepared solution: 1000ml=4000mcg
?= 180mcg
=1801000/4000
=45ml/hr
Correct Answer is A
Explanation
A. Obtain a blood pressure reading before the client gets out of beD This intervention is important because the client is prescribed medications that may affect blood pressure, such as antidepressants and sedatives. Monitoring blood pressure before changes in position can help prevent orthostatic hypotension and related complications.
B. Measure and record the client's urinary output every day: While monitoring urinary output is important for overall assessment, it may not be the most immediate concern given the client's recent surgery and medication regimen.
C. Provide the client with teaching regarding a cardiac diet: While education on a cardiac diet is important for cardiovascular health, addressing immediate concerns related to medication effects and post-surgical recovery takes priority.
D. Obtain the client's vital signs every 4 hours when awake: While vital sign monitoring is essential, the timing of every 4 hours may not be necessary during sleep, and obtaining blood pressure readings before changes in position is more critical to prevent adverse events.
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