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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 ["A","C"]

Explanation

A. Family health history: A comprehensive family health history is crucial as it can reveal a pattern of certain diseases within a family. The client's parents both had heart disease, and his father had diabetes, which significantly increases the client's risk for these conditions.
B. Homosexual Lifestyle: This is not a risk factor for heart disease. Sexual orientation does not inherently increase the risk of heart disease. The inclusion of this option reflects a common misconception and is not medically relevant.
C. History of hypertension: Even though the client's blood pressure is currently managed with atenolol, a history of hypertension is a significant risk factor for heart disease. It's important to explore the duration and control of hypertension over time.
D. Vegetarian diet: Generally, a vegetarian diet is associated with lower risk factors for heart disease, such as reduced blood pressure and lower cholesterol levels. However, it's important to ensure that the diet is well-balanced and includes all necessary nutrients.
E.While exercise is generally beneficial for heart health, it is possible to overdo it. However, the client's episode occurred during jogging, which is typically a moderate form of exercise. Unless the client is engaging in extreme levels of exercise, this is unlikely to be a significant risk factor.

A. Increase the intake of dark green leafy vegetables while taking warfarin. B. Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed. C. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D. Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin.

Correct Answer is C

Explanation

A. Increasing the intake of dark green leafy vegetables while taking warfarin can affect INR levels due to their high vitamin K content, potentially increasing the risk of bleeding.
B. Eating two servings of raw dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not recommended as it may affect INR levels.
C. Eating approximately the same amount of leafy green vegetables daily helps maintain consistent vitamin K intake, which is important for keeping INR levels stable while on warfarin therapy.
D. Avoiding all foods containing vitamin K is not necessary and may lead to nutritional
deficiencies; instead, it's important to consume a consistent amount of vitamin K-containing foods.

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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

Correct Answer is ["A","C"]

Explanation

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

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?