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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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Notify the emergency response team of the client's seizure: While the seizure is significant, it lasted less than 1 minute and resolved spontaneously. There is no need to call an emergency response team unless complications arise or the seizure becomes prolonged.
B. Keep orienting the client to time and space until he is less confused: While supportive, this is not the priority. Postictal confusion is expected and does not usually require active reorientation until the client regains baseline status.
C. Explain the postictal state that usually follows seizures: Providing reassurance and education to the spouse about postictal symptoms (such as confusion, lethargy, and altered responsiveness) is appropriate and therapeutic. It addresses her concern while monitoring the client for further changes.
D. Ask the wife to wait outside the room until the nurse can talk with her: This action excludes the spouse unnecessarily and delays communication. Involving the family promotes trust and understanding.

A. Assess pupillary response to light hourly. B. Initiate seizure precautions. C. Measure urinary output every hour. D. Monitor serum potassium frequently.

Correct Answer is C

Explanation

A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.

B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.

C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.

D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.

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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 C

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

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?