A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Notify child protective services of the client’s illicit drug use and probable child endangerment.

Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.

Choice B rationale

Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.

Choice C rationale

Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.

Choice D rationale

Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.

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Correct Answer is ["36"]

Explanation

Step 1 is: Convert 10 units to milliunits: 10 units × 1,000 milliunits/unit = 10,000 milliunits.

Step 2 is: Calculate the infusion rate: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min.

Step 3 is: Convert the infusion rate to mL/hour: 0.6 mL/min × 60 min/hour = 36 mL/hour. Final calculated answer: 36 mL/hour.

Correct Answer is []

Explanation

Rationale for correct condition: Hypoglycemia in neonates can present with jitteriness, low body temperature, and poor feeding. Normal blood glucose levels for neonates range from 40-60 mg/dL. The Ballard maturity rating of 37 weeks indicates that the neonate may have an immature glucose metabolism. Early recognition and treatment are crucial to prevent complications.

Rationale for correct actions:

Giving dextrose solution orally quickly increases blood glucose levels. This provides an immediate source of glucose to the neonate.
Performing a heel stick for blood glucose testing allows for accurate monitoring of glucose levels. Continuous assessment ensures timely intervention.

Rationale for correct parameters:

Blood glucose levels: Monitoring ensures that the neonate maintains normal glucose levels (40-60 mg/dL). This helps prevent hypoglycemia-related complications.
Temperature: Neonates with hypoglycemia often have low body temperature. Monitoring temperature aids in detecting and addressing hypothermia.

Rationale for incorrect conditions:

Altered respiratory function: The neonate has normal respiratory rate and heart rate.
Thermoregulation: Although temperature is low, the jitteriness is more indicative of hypoglycemia.
Sepsis: No signs of infection such as fever or elevated white blood cell count are present.

Rationale for incorrect actions:

Provide manual breaths with a bag-valve mask: Not necessary as the neonate's respiratory rate is normal.
Administer intravenous antibiotics: No signs of infection or sepsis.
Place the neonate under a radiant warmer: This addresses temperature but not blood glucose levels.

Rationale for incorrect parameters:

Respiratory rate: Normal, does not indicate hypoglycemia.
Oxygen saturation: No signs of respiratory distress.
Bilirubin levels: Not relevant to the current symptoms.

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A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["36"]

Explanation

Correct Answer is []

Explanation

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