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 ["45"]
Explanation
1mg=1000mcg
4mg= 41000= 4000mcg
Desired dose= 3mcg/min
Desired dose per hour=3mcg60= 180mcg Form the prepared solution: 1000ml=4000mcg
?= 180mcg
=1801000/4000
=45ml/hr
Correct Answer is A
Explanation
A. Reinforce the need for adequate hydration: Adequate hydration is essential for liquefying secretions in the lungs, especially in clients with COPD who may have increased mucus production. Proper hydration also supports cardiovascular function, particularly in clients with peripheral vascular disease.
B. Provide typed instructions for healthy diet selections: While diet is important for overall health, hydration is the priority in this scenario due to the client's respiratory and vascular conditions.
C. Explain a daily regimen: While educating the client about a daily regimen is important, ensuring adequate hydration takes precedence in this situation.
D. Demonstrate specific strengthening exercises: While exercise is beneficial for clients with COPD and PVD, ensuring proper hydration is more critical for respiratory and cardiovascular function in this scenario.
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