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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Wearing gloves while gardening is a recommended practice after a mastectomy, especially on the side where lymph nodes have been removed. This is to protect the skin and reduce the risk of infection, which could trigger lymphedema.
Choice B rationale
It is indeed recommended that blood pressures be taken in the unaffected arm after a mastectomy. This is because the pressure from the cuff can obstruct lymph flow and potentially trigger lymphedema in the arm where lymph nodes have been removed. Choice C rationale
Wearing clothing with elastic sleeves is not recommended after a mastectomy. Elastic bands can restrict lymph flow and increase the risk of lymphedema.
Choice D rationale
Similar to blood pressure measurements, it is recommended that blood specimens be drawn from the unaffected arm after a mastectomy. This is to avoid injury to the lymphatic system in the arm where lymph nodes have been removed, which could trigger lymphedema.
Correct Answer is B
Explanation
Choice A rationale
A negative pregnancy test is important to rule out pregnancy as a cause of abnormal uterine bleeding (AUB), but it is not the priority finding. Pregnancy is one of the common causes of AUB in reproductive-age women, but the user’s question is about prioritizing findings, and other choices are more critical to assess the patient’s condition.
Choice B rationale
Hemoglobin and hematocrit levels are crucial in assessing the severity of AUB. Chronic heavy or prolonged uterine bleeding may cause iron deficiency anemia. Therefore, these tests are prioritized to determine the patient’s blood volume and to plan appropriate interventions.
Choice C rationale
While an elevated white blood cell count could indicate an infection, which can also cause AUB, it is not the priority in this case. Infections are less common causes of AUB, and the symptoms would likely include pain, fever, or abnormal discharge.
Choice D rationale
Serum cholesterol levels are not directly related to AUB. While it’s important to monitor cholesterol levels for overall health and cardiovascular risk management, it’s not a priority in the assessment of AUB12.
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