A nurse is assisting with the care of a newborn who is 4 hr old.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

- Potential Condition: Hypoglycemia

- Rationale: The jitteriness and weak cry can be signs of hypoglycemia, which is common in newborns, especially those with higher birth weights or whose mothers have diabetes or, in this case, a history of substance use during pregnancy.

Actions to Take:

1. Reinforce with the parent to feed the newborn: Feeding can help to stabilize the newborn's blood sugar levels.

2. Anticipate a prescription to obtain a capillary blood sample: This will confirm the diagnosis by measuring the newborn's blood glucose levels.

Parameters to Monitor:

1. Temperature: To ensure the newborn maintains a normal body temperature, as hypothermia can be associated with hypoglycemia.

2. Respiratory status: To monitor for any changes that could indicate worsening of the condition or other complications.

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Correct Answer is A

Explanation

A. A respiratory rate of 10/min indicates magnesium sulfate toxicity, which can cause respiratory depression. Close monitoring of respiratory rate is essential to identify and manage potential toxicity.
B. Urine output of 40 mL/hr is not an immediate sign of toxicity but requires monitoring. Decreased urine output can be a sign of complications, but it is not the primary indicator of magnesium sulfate toxicity.
C. Nausea is a common side effect of magnesium sulfate but not necessarily indicative of toxicity. More severe symptoms like respiratory depression are critical for diagnosing toxicity.
D. Facial flushing is a common, mild side effect of magnesium sulfate and not a sign of toxicity. Monitoring for more severe symptoms is essential to assess for toxicity.

A. Notify the provider. B. Assist the client to empty her bladder. C. Monitor perineal pads for clots. D. Administer a prescribed analgesic.

Correct Answer is B

Explanation

A. Notifying the provider may be necessary if the problem persists, but the first step is to address the most likely cause of the deviation.
B. A fundus that is firm but deviated to the left suggests that the bladder may be distended. Emptying the bladder can help the uterus to return to its midline position and promote proper uterine involution.
C. Monitoring perineal pads for clots is important, but the first action should be to resolve the potential cause of the fundal deviation.
D. Administering an analgesic is not a priority action for addressing fundal deviation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor. The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

Correct Answer is A

Explanation

A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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