Patient data
The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities
Which 6 orders take priority?
Transfer to NICU
Keep in warmer with bilirubin lights
Bolus of 2 ml/kg glucose 10% IV
Blood glucose level
Contact Respiratory Therapy for ABG and oxygen therapy
Feed immediately
Apply dextrose (sugar) gel inside the baby's cheek
Echocardiogram
Monitor for respiratory distress
Monitor temperature every 30 minutes
Correct Answer : C,D,E,F,I,J
A. Transfer to NICU - While NICU care is important, immediate stabilization takes precedence.
B. Keep in warmer with bilirubin lights - This is important for thermoregulation and managing jaundice but is not the most immediate concern.
C. Bolus of 2 ml/kg glucose 10% IV - This is critical to address the hypoglycemia (blood glucose 35 mg/dl).
D. Blood glucose level - Monitoring is essential for ongoing assessment of hypoglycemia.
E. Contact Respiratory Therapy for ABG and oxygen therapy - Given the high respiratory rate and potential for respiratory distress, this is a priority.
F. Feed immediately - Feeding can help stabilize blood glucose levels.
G. Apply dextrose (sugar) gel inside the baby's cheek - This is an alternative to IV glucose but less immediate than a bolus.
H. Echocardiogram - Important for cardiac assessment but not an immediate priority.
I. Monitor for respiratory distress - Essential due to the high respiratory rate and risk of complications from maternal diabetes.
J. Monitor temperature every 30 minutes - Important for detecting hypothermia due to the low axillary temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This hernia is a normal variation that resolves without treatment: Umbilical hernias are common in infants and usually resolve on their own by around 1 to 2 years of age without any specific treatment.
B. An abdominal binder can be worn daily to reduce the protrusion: Using an abdominal binder is not recommended for treating umbilical hernias in infants, as they typically resolve spontaneously and do not require intervention.
C. Restrictive clothing will be adequate to help the hernia go away: Restrictive clothing is not necessary and will not affect the resolution of an umbilical hernia in infants.
D. The quarter should be secured with an elastic bandage wrap: Securing a quarter over the umbilicus with an elastic bandage wrap is not an appropriate treatment for an umbilical hernia and may cause harm.
Correct Answer is C
Explanation
A. Refusing one meal is concerning for anorexia nervosa, but it does not pose an immediate safety threat and can be monitored closely.
B. Being yelled at may cause distress but is not an urgent threat to safety or health.
C. Pacing in a client with bipolar disorder can signal severe agitation, risk of aggression, or inability to control impulses, requiring immediate intervention to prevent harm.
D. Refusal to participate in group signals withdrawal or low mood, but it is not immediately dangerous.
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