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 B
Explanation
Choice A rationale
While lying down can be part of the breast self-examination process, the arms should not be at the side. Instead, they should be raised above the head to spread the breast tissue evenly over the chest.
Choice B rationale
The finger pads of the three middle fingers are used to apply pressure to the breast during a self-exam. This allows for a thorough examination of the breast tissue for any lumps or abnormalities. This is the correct method for performing a breast self-examination.
Choice C rationale
Even if the breast feels fine, it is important to check under the arm. The lymph nodes located in this area can swell due to breast cancer.
Choice D rationale
While examining the breast, it is not necessary to work from left to right towards the ribs. The important thing is to cover the entire breast area, including the armpit.
Correct Answer is ["220.6 "]
Explanation
Here's the breakdown of the calculation:
Calculate the concentration of the medication after adding diluent:
Concentration = (Amount of medication) / (Total volume)
Concentration = (1 gm) / (3.4 mL)
Concentration = 0.294 mg/mL
Determine the desired amount of medication per dose:
Desired amount = 750 mg
Calculate the volume of the prepared solution needed to deliver the desired amount of medication:
Volume = (Desired amount) / (Concentration)
Volume = (750 mg) / (0.294 mg/mL)
Volume = 2551.36 mL ≈ 220.6 mL (rounded to one decimal place)
Therefore, you would need to administer approximately 220.6 mL of the prepared solution per dose to deliver 750mg of cefotaxime.
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