Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry.
What is the top priority nursing action?

Notify the clinician immediately.

Test the blood glucose level.

Start an intravenous line with D5W.

Document the event in the nurse’s notes.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Notifying the clinician immediately may be necessary, but it is not the first action to take. The nurse should first identify the cause of the baby’s symptoms.
Choice B rationale
The baby’s symptoms are indicative of hypoglycemia, a common condition in infants of mothers with diabetes. Testing the blood glucose level would confirm this diagnosis and allow for appropriate treatment.
Choice C rationale
Starting an intravenous line with D5W may be necessary if the baby’s blood glucose level is low. However, the first step should be to confirm the diagnosis by testing the blood glucose level.
Choice D rationale
Documenting the event in the nurse’s notes is important, but it is not the first action to take. The nurse should first address the baby’s immediate needs.

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Correct Answer is D

Explanation

Choice A rationale
Hypothermia, decreased muscle tone, and a weak sucking reflex are not typically exhibited by newborns whose mothers are substance abusers. These symptoms could be indicative of other medical conditions.
Choice B rationale
Excessive sleep, a weak cry, and a diminished grasp reflex are not the most common behaviors exhibited by newborns of substance-abusing mothers.
Choice C rationale
Circumoral cyanosis, a hyperactive Babinski reflex, and constipation are not typically seen in newborns of substance-abusing mothers. These symptoms could be indicative of other medical conditions.
Choice D rationale
Newborns of substance-abusing mothers often exhibit decreased amounts of sleep, a hyperactive Moro reflex, and difficulty feeding. These symptoms are related to withdrawal from the substances the mother was using during pregnancy.

A. “A Pap smear is almost always helpful in identifying this type of cancer.”. B. “There’s a blood test for a marker, CA-125, that if elevated indicates cancer.”. C. “A genetic test for two genes, if positive, will identify the ovarian cancer.”. D. “Currently there is no reliable screening test for ovarian cancer.”.

Correct Answer is D

Explanation

Choice A rationale
A Pap smear is not helpful in identifying ovarian cancer. It is used to detect cervical cancer, not ovarian cancer.
Choice B rationale
While the CA-125 blood test can indicate the presence of ovarian cancer if the levels are elevated, it is not a reliable screening test. This is because high levels of CA-125 can also be caused by common conditions such as endometriosis and pelvic inflammatory disease.
Choice C rationale
Genetic testing for two genes (BRCA1 and BRCA2) can identify an increased risk for developing ovarian cancer, but it does not diagnose the disease itself.
Choice D rationale
Currently, there is no reliable screening test for ovarian cancer. The most effective strategies for early detection are being aware of the symptoms and maintaining regular check-ups with your healthcare provider.

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Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. What is the top priority nursing action?

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Naxlex Comprehensive Predictor Exams

What behaviors are often exhibited by newborns whose mothers are substance abusers?

Correct Answer is D

Explanation

The daughter of a woman who has been diagnosed with ovarian cancer asks the nurse about screening for this cancer. What would be the most appropriate response by the nurse?

Correct Answer is D

Explanation

After conducting an in-service program about ovarian cysts, what type of cyst would the nurse expect the group to identify as being commonly found in females of reproductive age and regresses with the menstrual cycle?

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After instructing a woman on how to conduct a breast self-examination, which statement would suggest that the nurse’s instructions were effective?

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry.
What is the top priority nursing action?