The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Bolus of 2 ml/kg glucose 10% IV.

Feed immediately.

Echocardiogram.

Monitor for respiratory distress.

Apply dextrose gel inside the baby’s cheek.

Answer and Explanation

The Correct Answer is E

Choice A rationale

Administering a bolus of 2 ml/kg glucose 10% IV is important for hypoglycemia management, providing rapid glucose delivery. Normal blood glucose level for neonates is 45-90 mg/dL. Severe hypoglycemia requires immediate intervention.

Choice B rationale

Immediate feeding can stabilize blood glucose levels by providing a sustained energy source. Breastfeeding or formula feeding aids in maintaining glucose homeostasis, supporting neonatal metabolic needs and preventing hypoglycemia.

Choice C rationale

An echocardiogram is a non-invasive diagnostic test used to evaluate cardiac structure and function. It is not a priority intervention compared to managing hypoglycemia or respiratory distress, as it does not address immediate neonatal needs.

Choice D rationale

Monitoring for respiratory distress involves observing signs such as tachypnea, grunting, nasal flaring, and retractions. Early identification of respiratory issues is crucial in neonates to prevent complications like respiratory failure.

Choice E rationale

Applying dextrose gel inside the baby’s cheek can quickly raise blood glucose levels in cases of mild hypoglycemia. It is an effective short-term intervention for stabilizing blood glucose while preparing for further treatment.

Choice F rationale

Monitoring temperature every 30 minutes helps detect hypothermia or hyperthermia. Normal neonatal temperature is 36.5-37.5°C (97.7-99.5°F). Maintaining thermal stability is vital to prevent metabolic complications in newborns.

Choice G rationale

Contacting respiratory therapy for arterial blood gas (ABG) and oxygen therapy ensures proper oxygenation and ventilation. ABGs provide critical information on acid-base status, and oxygen therapy supports adequate tissue oxygenation.

Choice H rationale

Keeping the neonate in a warmer with bilirubin lights (phototherapy) treats hyperbilirubinemia by converting bilirubin into a water-soluble form for excretion. Normal bilirubin levels are <12 mg/dL in term neonates. It is not an immediate priority.

Choice I rationale

Transferring to a neonatal intensive care unit (NICU) provides specialized care, including advanced monitoring and interventions for critically ill neonates. NICUs have resources for managing complex medical conditions and ensuring optimal outcomes.

Choice J rationale

Measuring blood glucose levels is essential for assessing neonatal glucose status, especially in high-risk infants. Normal blood glucose levels for neonates are 45-90 mg/dL. Identifying hypoglycemia is critical for prompt treatment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Yogurt is not a significant source of folic acid, providing minimal contribution to the daily requirement needed during pregnancy.

Choice B rationale

Whole milk is not a substantial source of folic acid, contributing little to meeting the daily folic acid requirement for pregnant women.

Choice C rationale

Collard greens are rich in folic acid, but the client's dislike for green leafy vegetables makes them unsuitable in this context.

Choice D rationale

Strawberries are a good source of folic acid and can help meet the recommended daily intake for folic acid in pregnant women.

A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Correct Answer is C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

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

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

Correct Answer is D

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

Which action is most important for the nurse to implement?

A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?