Patient Data

Exhibits
The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.

Parents report infant can choke

Infant refused bottle after 15 mL

Parents requested nurse feed infant

Respirations 38 breaths/minute

Infant fell asleep after feeding

Infant temperature 98.6° F (37.0° C)

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Rationale:

Parents report infant can choke: Parents’ recognition of choking risk indicates they understood the teaching about feeding precautions and are observing the infant’s cues, which is a desired outcome of education.
Infant refused bottle after 15 mL: Refusal to finish a bottle indicates ongoing feeding difficulties, suggesting interventions have not fully addressed the infant’s feeding challenges.
Parents requested nurse feed infant: Reliance on the nurse to feed the infant shows parents are not yet fully confident or comfortable applying the feeding techniques independently, indicating partial effectiveness.
Respirations 38 breaths/minute: Normalization of respiratory rate post-feeding reflects that the infant is tolerating feeding better and maintaining adequate oxygenation.
Infant fell asleep after feeding: Falling asleep after such a small intake, especially after crying and refusing the bottle, suggests that the infant is fatigued and exhausted from the effort of feeding. This indicates that the feeding was not successful.
Infant temperature 98.6° F (37.0° C): Reduction of fever indicates effective management of infection, supporting that interventions like acetaminophen and antibiotics are working.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Assess deep tendon reflexes (DTRs) every 4 hours: Monitoring DTRs is essential to detect early signs of magnesium toxicity, but the frequency of assessment alone does not immediately prevent life-threatening complications.

B. Provide a quiet environment with subdued lighting: A calm environment helps reduce maternal stress and may support labor progression, but it does not address the primary safety concern associated with magnesium sulfate therapy.

C. Have calcium gluconate immediately available: Calcium gluconate is the antidote for magnesium sulfate toxicity. Having it readily available is the highest priority because magnesium toxicity can rapidly depress neuromuscular and respiratory function, requiring immediate intervention.

D. Insert an indwelling urinary catheter with a urimeter to monitor hourly output: Monitoring urine output is important to assess renal function and magnesium excretion, but immediate availability of the antidote takes precedence in preventing life-threatening complications.

A. Family history of breast cancer. B. Tanner stage 2 of breast development. C. Hemoglobin of 10 g/dL (100 g/L). D. Low body mass index (BMI).

Correct Answer is D

Explanation

Rationale:

A. Family history of breast cancer: While a family history of breast cancer is important for long-term health risk assessment, it does not directly affect the timing of menarche or cause delayed menstruation in adolescents.

B. Tanner stage 2 of breast development: Tanner stage 2 indicates early pubertal development, which is typical for girls approaching menarche. Although this shows puberty has begun, it is not itself a cause of delayed menstruation.

C. Hemoglobin of 10 g/dL (100 g/L): A hemoglobin level of 10 g/dL represents mild anemia, which may affect overall health but is not usually sufficient alone to delay the onset of menstruation.

D. Low body mass index (BMI): A low BMI can result in insufficient body fat necessary for the hormonal regulation of menstruation. Adolescents with low BMI may experience delayed menarche due to decreased estrogen production and energy availability required for the onset of ovulatory cycles.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Patient Data Exhibits The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mm Hg to 140/90 mm Hg. Which nursing protocol has the highest priority?

Correct Answer is C

Explanation

A 14-year-old female client comes into the clinic for an annual exam and expresses concern about not starting her menstrual cycle. Which finding should the nurse recognize as potential cause of delayed menstration? Reference Range: Hemoglobin [10 to 15.5 g/dL (100 to 155 g/L)]

Correct Answer is D

Explanation

Patient Data Exhibits The nurse identifies that the client is experiencing dropdown as evidenced by dropdown.

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?

When inspecting the ears of a toddler without the use of an otoscope, which action should the nurse take?

How many mL of urine output should the nurse document for an infant's wet diaper weight of 85 grams compared to the dry diaper weight of 50 grams? (Enter numeric value only.)

A client with diet controlled gestational diabetes mellitus arrives for a routine appointment at the prenatal clinic. The client's glycosylated hemoglobin (HbA1C) is 5%. Which action should the nurse take? Reference Range: Glycosylated hemoglobin (HbA1C) [4% to 5.9% ]

Patient Data

Exhibits
The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.