A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe

Supplement feedings with dextrose water

Administer intravenous dextrose

Obtain a total serum bilirubin

Encourage breastfeeding every 2 hr

Prepare for an exchange transfusion

Obtain blood cultures

Answer and Explanation

Correct Answer : C,D

A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.

B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.

C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.

D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.

E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.

F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.

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Correct Answer is A

Explanation

A. Changing a perineal pad only every 4 hours may indicate excessive bleeding or hemorrhage, which requires immediate assessment.
B. A urine output of 750 mL in 6 hours is within normal limits (about 125 mL/hr).
C. 1+ deep tendon reflexes indicate decreased reflexes, which is expected during magnesium sulfate therapy and generally not an immediate concern.
D. Abdominal cramping during breastfeeding is common due to uterine contractions and is usually not urgent.

A. Abdominal assessment B. Low back pain C. Uterine contractions D. Abdominal cramping E. Fundal height F. Fetal heart rate

Correct Answer is ["A","B","D"]

Explanation

A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.

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A nurse is caring for the newborn 1 day after birth Exhibits Select 2 orders which the nurse should anticipate that the provider will prescribe

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe