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Patient data

Exhibits

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

Answer and Explanation

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

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Correct Answer is C

Explanation

A. Blood alcohol level of 0.09% (90 mmol/L): Although an elevated blood alcohol level could contribute to slurred speech and unsteady gait, the client's clinical presentation is more consistent with lithium toxicity rather than alcohol intoxication. However, it's important to assess for recent alcohol consumption and potential interactions with medications.

B. Six hours of sleep in the past three days: Sleep disturbances are common in bipolar disorder, but in this scenario, the more concerning issue is the potential lithium toxicity, as indicated by the client's symptoms.

C. Serum lithium level of 1.6 mEq/L (1.6 mmol/L): Correct! A serum lithium level above the therapeutic range (greater than 1.2 mEq/L) can lead to adverse effects such as slurred speech, ataxia, and tremors. This finding indicates lithium toxicity and requires immediate intervention.

D. Weight loss of 10 pounds (4.5 kg) in past month: Weight changes can be a concern in bipolar disorder, but in this case, the symptoms are more suggestive of lithium toxicity rather than related to weight loss

A. Feed the infant every 4 hours. B. Perform diaper changes under the light. C. Reposition the infant every 2 hours. D. Cover with a receiving blanket.

Correct Answer is C

Explanation

A. Feeding the infant every 4 hours is important for nutrition but not specifically related to phototherapy.
B. Performing diaper changes under the light is important to ensure the effectiveness of

phototherapy but repositioning is more crucial for avoiding pressure points and ensuring even exposure to the light.
C. Repositioning the infant every 2 hours helps ensure even exposure to the phototherapy light, reducing the risk of complications and maximizing effectiveness.
D. Covering the infant with a receiving blanket may interfere with the effectiveness of phototherapy and is not recommended.

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Patient data Exhibits The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities Which 6 orders take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dl (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

Correct Answer is C

Explanation

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Patient data

Exhibits

The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities

Which 6 orders take priority?