The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Bolus of 2 ml/kg glucose 10% IV.

Feed immediately.

Echocardiogram.

Monitor for respiratory distress.

Apply dextrose gel inside the baby’s cheek.

Answer and Explanation

The Correct Answer is E

Choice A rationale

Administering a bolus of 2 ml/kg glucose 10% IV is important for hypoglycemia management, providing rapid glucose delivery. Normal blood glucose level for neonates is 45-90 mg/dL. Severe hypoglycemia requires immediate intervention.

Choice B rationale

Immediate feeding can stabilize blood glucose levels by providing a sustained energy source. Breastfeeding or formula feeding aids in maintaining glucose homeostasis, supporting neonatal metabolic needs and preventing hypoglycemia.

Choice C rationale

An echocardiogram is a non-invasive diagnostic test used to evaluate cardiac structure and function. It is not a priority intervention compared to managing hypoglycemia or respiratory distress, as it does not address immediate neonatal needs.

Choice D rationale

Monitoring for respiratory distress involves observing signs such as tachypnea, grunting, nasal flaring, and retractions. Early identification of respiratory issues is crucial in neonates to prevent complications like respiratory failure.

Choice E rationale

Applying dextrose gel inside the baby’s cheek can quickly raise blood glucose levels in cases of mild hypoglycemia. It is an effective short-term intervention for stabilizing blood glucose while preparing for further treatment.

Choice F rationale

Monitoring temperature every 30 minutes helps detect hypothermia or hyperthermia. Normal neonatal temperature is 36.5-37.5°C (97.7-99.5°F). Maintaining thermal stability is vital to prevent metabolic complications in newborns.

Choice G rationale

Contacting respiratory therapy for arterial blood gas (ABG) and oxygen therapy ensures proper oxygenation and ventilation. ABGs provide critical information on acid-base status, and oxygen therapy supports adequate tissue oxygenation.

Choice H rationale

Keeping the neonate in a warmer with bilirubin lights (phototherapy) treats hyperbilirubinemia by converting bilirubin into a water-soluble form for excretion. Normal bilirubin levels are <12 mg/dL in term neonates. It is not an immediate priority.

Choice I rationale

Transferring to a neonatal intensive care unit (NICU) provides specialized care, including advanced monitoring and interventions for critically ill neonates. NICUs have resources for managing complex medical conditions and ensuring optimal outcomes.

Choice J rationale

Measuring blood glucose levels is essential for assessing neonatal glucose status, especially in high-risk infants. Normal blood glucose levels for neonates are 45-90 mg/dL. Identifying hypoglycemia is critical for prompt treatment.

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Correct Answer is D

Explanation

Choice A rationale

Epidural placement requires assessing the current cervical dilation and fetal station. Without this information, premature epidural placement can impede labor progress or mask signs of complications.

Choice B rationale

A bolus of intravenous fluids is necessary before epidural anesthesia to prevent hypotension. However, assessing cervical dilation first ensures that it is appropriate to proceed with pain management.

Choice C rationale

Decreasing the oxytocin infusion rate is not the initial priority. The current cervical dilation and effacement need to be assessed to determine the appropriate management of labor and pain control.

Choice D rationale

Determining current cervical dilation is the first action to evaluate labor progress and make informed decisions regarding pain management and epidural placement, ensuring safe and effective care.

A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Correct Answer is C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

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The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?

Correct Answer is D

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell (WBC) count is 15,000/mm³ (15 x 10⁹/L). Which action should the nurse take first?

Which action is most important for the nurse to implement?

Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

When is the best time to administer a rubella vaccine to a client?

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.