A nurse is caring for a newborn who is 4 hours old in the Neonatal Intensive Care Unit (NICU).
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 []

•   Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
•   Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
•   Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.

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Correct Answer is B

Explanation

Choice A rationale
The influenza vaccine is recommended for all pregnant women, but it is not the only vaccine that should be administered to a pregnant woman who has received no immunizations during childhood.
Choice B rationale
The Tetanus, Diphtheria, Pertussis (Tdap) vaccine is recommended for all pregnant women, regardless of their prior immunization status. This vaccine protects against three serious diseases caused by bacteria. The antibodies that the pregnant woman’s body makes in response to the vaccine are passed on to the baby through the placenta, providing the baby with short-term protection against these diseases until they can receive their own vaccines.
Choice C rationale
The Hepatitis B vaccine is not typically given during pregnancy unless the woman is at risk for Hepatitis B infection.
Choice D rationale
The Pneumococcal vaccine is not typically given during pregnancy unless the woman has certain health conditions that increase her risk for pneumococcal disease

A. I will report joint pain that develops after the immunization to my provider immediately B. I should avoid breastfeeding for 2 weeks following the immunization C. I should avoid becoming pregnant for at least 1 month following the immunization D. I will receive a series of three immunizations and each one will be a month apart

Correct Answer is C

Explanation

Choice A rationale
Joint pain is not a common side effect of the rubella immunization.
Choice B rationale
Breastfeeding is not typically contraindicated after receiving the rubella immunization.
Choice C rationale
Women are advised to avoid becoming pregnant for at least one month following the rubella immunization because the vaccine contains a live virus.

Choice D rationale
The rubella immunization is not typically given as a series of three immunizations.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

Correct Answer is B

Explanation

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

Correct Answer is C

Explanation

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