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Newborn Complications
Study Questions
Dosage Calculation RN Maternal Newborn Proctored Assessment 3.1
A nurse is preparing to administer docusate sodium PO to a postpartum client who has a prescription for 200 mg/day in two equally divided doses. The client states she has trouble swallowing tablets and capsules. Therefore, the nurse has obtained docusate sodium liquid 50 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it
Explanation
The question is asking for the amount of docusate sodium liquid the nurse should administer per dose. The prescription is for 200 mg/day in two equally divided doses, and the liquid form of the medication is 50 mg/5 mL.
Step 1 is to determine the amount of medication needed per dose. Since the total daily dose is 200 mg and it’s divided into two doses, each dose will be 200 mg ÷ 2 = 100 mg.
Step 2 is to convert this dose from mg to mL using the concentration of the liquid medication. The concentration is 50 mg/5 mL, which means that 1 mL contains 50 mg ÷ 5 = 10 mg of the medication.
Step 3 is to calculate the volume of the medication needed for a 100 mg dose. Since 1 mL contains 10 mg, we need 100 mg ÷ 10 mg/mL = 10 mL.
So, the nurse should administer 10 mL of docusate sodium liquid per dose.
A nurse is preparing to administer enoxaparin 55 mg subcutaneous to a client who has a deep-vein thrombosis after undergoing a cesarean birth. Available is enoxaparin solution for injection 60 mg/0.6 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
60mg=0.6
55mg= 55*0.6/60
Volume (mL) = 0.55 mL
Rounding to the nearest tenth, the nurse should administer 0.6 mL of enoxaparin solution to the client.
A nurse prepares to administer 0.9% sodium chloride 200 mL over 30 min. The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate (mL/hr) = 200 mL / 0.5 hr Infusion rate (mL/hr) = (200 mL/hr) *2
= 400mls/hr
1.A nurse is caring for a client who is postpartum and has a prescription for oxytocin 10 units IM one time only for the saturation of a perineal pad in 15 min or less. How should the nurse interpret this prescription?
Explanation
The correct answer is Choice B.
Choice A rationale: This is incorrect because the prescription is for one time only, not for repeated doses.Giving the medication each time the client saturates the perineal pad within 15 min could cause uterine hyperstimulation, water intoxication, or hypotension1.
Choice B rationale: This is correct because the prescription is for one time only and the indication is saturation of a perineal pad in 15 min or less.This is a sign of postpartum hemorrhage, which is a common and potentially life-threatening complication of childbirth2.Oxytocin is a uterotonic agent that helps the uterus contract and reduce bleeding3.
Choice C rationale: This is incorrect because waiting 15 min to administer the medication after the client saturates a perineal pad could result in excessive blood loss and hypovolemic shock. The medication should be given as soon as possible after the indication is met.
Choice D rationale: This is incorrect because offering the medication now to prevent saturation of perineal pad is not the intended use of the prescription. The medication is for treatment, not prevention, of postpartum hemorrhage. Prophylactic oxytocin is usually given intravenously or intramuscularly during or immediately after the delivery of the placenta.
A nurse is preparing to administer enoxaparin 55 mg subcutaneously to a client who has a deep-vein thrombosis after undergoing a cesarean birth. Available is enoxaparin solution for injection 60 mg/0.6 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
60mg=0.6ml 55mg= 55*0.6/60
Volume (mL) = 0.55 mL
Rounding to the nearest tenth, the nurse should administer 0.6 mL of enoxaparin solution to the client.
A nurse is reviewing a new prescription for propranolol 200 mg PO daily divided in equal doses every 12 hr for a client who has migraine headaches during the premenstrual period. Available is propranolol solution 4 mg/mL. How many mL should the client self-administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
mL = mg / 4 mL = 100 / 4
mL = 25 / 1
This means that the client needs to take 25 mL of the propranolol solution every 12 hours to get the prescribed dose of 200 mg per day
A nurse is caring for a client who is postpartum and has a prescription for oxytocin 10 units IM one time only for the saturation of a perineal pad in 15 min or less. How should the nurse interpret this prescription?
Explanation
The correct answer is choice B: The prescription states to administer the medication "one time only" if the client saturates the perineal pad within 15 minutes. The nurse should give the medication once when the pad becomes saturated within the specified time frame.
A. Give the medication each time the client saturates the perineal pad within 15 min.
This answer choice is incorrect. The prescription states that the medication is to be given "one time only" for the saturation of a perineal pad in 15 minutes or less. Therefore, it does not specify to administer the medication multiple times if the pad continues to saturate.
C. Wait 15 min to administer the medication after the client saturates a perineal pad.
This answer choice is incorrect. The prescription does not state to wait for 15 minutes before administering the medication. It specifies that the medication should be given if the pad becomes saturated within 15 minutes or less.
D. Offer the medication now to prevent saturation of perineal pad.
This answer choice is incorrect. The prescription does not indicate that the medication should be offered preemptively to prevent saturation of the perineal pad. It is only to be administered if the saturation occurs within 15 minutes
A nurse is caring for a newborn who weighs 3,500 g. The nurse should record the newborn's weight as how many kg. (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
1000g=1kg 3500g=3500*1/1000
=3.5kg
A nurse is caring for a client who is postpartum and has a prescription for oxytocin 10 units IM one time only for the saturation of a perineal pad in 15 min or less. How should the nurse interpret this prescription?
Explanation
The correct answer is choice B. The prescription indicates that the medication should be given "one time only" if the client saturates the perineal pad within 15 minutes.
The nurse should administer the medication once the pad becomes saturated within the specified time frame.
A. Give the medication each time the client saturates the perineal pad within 15 min.
This answer choice is incorrect. The prescription states that the medication should be administered "one time only" for the saturation of a perineal pad in 15 minutes or less. It does not specify giving the medication multiple times.
C. Wait a minute to administer the medication after the client saturates a perineal pad.
This answer choice is incorrect. The prescription does not mention waiting for any specific time before administering the medication. It states that the medication should be given if the pad becomes saturated within 15 minutes or less.
D. Offer the medication now to prevent saturation of the perineal pad.
This answer choice is incorrect. The prescription does not indicate that the medication should be offered preemptively to prevent saturation of the perineal pad. It is only to be administered if the saturation occurs within 15 minutes.
A nurse is caring for an infant. The mother states the infant took 2.5 oz of formula at the last feeding. How many mL should the nurse document as the intake on the 1&O record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
One US fluid ounce is equal to 29.6 milliliters. Therefore Formula intake in mL = Formula intake in oz × 29.6 Plugging in the given value of 2.5 oz, we get:
Formula intake in mL = 2.5 × 29.6 Formula intake in mL = 74mls
A nurse assists with the admission of a client to the postpartum unit and reviews the client's prescribed medications. The nurse should clarify which of the following prescriptions with the provider.
Explanation
Bisacodyl is a stimulant laxative that works by increasing the activity of the intestines to cause a bowel movement. It is usually used on a short-term basis to treat constipation or to empty the bowels before surgery or certain medical procedures. However, bisacodyl should not be used in postpartum clients who have had a cesarean delivery or an episiotomy, as it may cause straining and increase the risk of bleeding or infection. Therefore, the nurse should clarify this prescription with the provider and suggest an alternative laxative that is safer for postpartum clients, such as docusate sodium or psyllium.
Calcium carbonate 750 mg PO.
There is no need to clarify this prescription. Calcium carbonate is a common supplement used to provide calcium to the body, and it is typically taken orally.
Oxycodone 5 mg PO every 4 hr PRN for severe pain.
There is no need to clarify this prescription. Oxycodone is a strong opioid analgesic commonly used for severe pain management, and the specified dose and frequency are within the usual range.
Ibuprofen 600 mg PO every 6 hr PRN for moderate pain.
There is no need to clarify this prescription. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for pain relief, including moderate pain. The specified dose and frequency are within the usual range.
A nurse is preparing to administer ferrous sulfate 120 mg PO two times each day with meals to a client who is at 12 weeks of gestation and has anemia. Available is ferrous sulfate syrup 90 mg/5 mL. How many ml. should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
The question is asking for the volume of ferrous sulfate syrup that the nurse should administer per dose. The desired dose is 120 mg and the available syrup has a concentration of 90 mg/5 mL.
Let’s calculate this step by step:
Step 1: Identify the desired dose, which is 120 mg.
Step 2: Identify the concentration of the available medication, which is 90 mg/5 mL.
Step 3: Set up the equation to solve for the volume (V) in mL. The equation is (Desired dose ÷ Concentration) × Volume of the concentration = V.
Step 4: Substitute the known values into the equation: (120 mg ÷ 90 mg) × 5 mL = V.
Step 5: Solve the equation: V = (1.33) × 5 mL = 6.67 mL.
So, the nurse should administer approximately 6.7 mL of the ferrous sulfate syrup per dose.
A nurse is preparing to administer 0.45% sodium chloride 1,000 mL IV to infuse over 6 hr to a postpartum client. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
To find the infusion rate in mL/hr, divide the total volume of fluid by the total time of infusion.
Total volume of fluid = 1,000 mL Total time of infusion = 6 hr
Infusion rate = 1,000 mL / 6 hr = 166.67 mL/hr
Round the answer to the nearest whole number: 167 mL/hr
A nurse is caring for a newborn who weighs 6 lbs. The nurse should record the newborn's weight as how many g? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
The nurse should record the newborn's weight as 2722 g. 1 pound is equal to 453.59237 grams,
6 pounds times 453.59237 grams = 2721.55422 grams
Rounded off = 2722 grams.
A nurse is preparing to administer fentanyl 100 mcg IM one time for pain to a client who is in labor and requests pain medication. Available is fentanyl injection 0.05 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Volume (mL) = Dose (mcg) / Concentration (mcg/mL) Volume (mL) = 100 mcg / 50 mcg/mL
Volume (mL) = 2 mL
Therefore, the nurse should administer 2 mL of fentanyl injection 0.05 mg/mL to the client
A nurse is preparing to administer phytonadione 0.5 mg IM to a newborn. Available in phytonadione injection 1 mg/0.5 mL. How many mL should the nurse plan to administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Amount of injection in mls = Dose ordered (mg) / Dose available Therefore:
Amount of injection in mls = 0.5 mg Therefore;
Amount of injection in mls = 0.5 mg x 0.5 mL / 1 mg Amount of injection in mls = 0.25 mL
A nurse is preparing to administer digoxin 0.25 mg PO to a client who has heart failure and is at 35 weeks of gestation. Available is digoxin 0.125 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
To calculate the number of tablets to administer, you need to divide the prescribed dose by the available dose. In this case, the prescribed dose is 0.25 mg and the available dose is 0.125 mg. Therefore, the number of tablets is:
0.25 mg / 0.125 mg = 2 tablets
The nurse should administer 2 tablets of digoxin 0.125 mg to the client.
A nurse is preparing to administer nalbuphine 10 mg IV via intermittent bolus to a client who is in active labor. Available is nalbuphine 20 mg/ml. How many mL should the nurse plan to administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Dose / Concentration = Volume Plug in the values from the question:
10 mg / 20 mg/ml = 0.5 ml
Round the answer to the nearest tenth:
=0.5 ml
A nurse is preparing to administer lactated Ringer's 1,500 mL IV over 8 hr to a pregnant client who has gastroenteritis. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate = Volume / Time Therefore;
Infusion rate= 1,500 mL / 8 hr
Infusion rate = 187.5 mL/hr
Rounded off to the nearest whole number; 188ml/hr
A nurse is preparing to administer oxycodone 10 mg PO every 6 hr PRN for severe pain to a client who is postpartum following a cesarean birth. Available in oxycodone 5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Number of tablets = (Dose ordered / Dose available) x Frequency Number of tablets = (10 mg / 5 mg) x 1
Number of tablets = 2 x 1 Number of tablets = 2
A nurse is preparing to administer phytonadione 0.5 mg IM to a newborn. Available is phytonadione injection 1 mg/0.5 mL. How many mL should the nurse plan to administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
volume = 0.5 mg / (1 mg/0.5 mL) volume = 0.5 mg x 0.5 mL / 1 mg volume = 0.25 mL
A nurse is preparing to administer lactated Ringer's 1,500 mL IV over 8 hr to a pregnant client who has gastroenteritis. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate= Volume / Time
Therefore;
Infusion rate = 1,500 mL / 8 hr Infusion rate = 187.5 mL/hr
Rounded off to the nearest whole number; 188ml/hr
A nurse is preparing to administer dobutamine 12 mcg/kg/min by continuous IV infusion to a preterm newborn who weighs 2 kg. Available is dobutamine 250 mg in 500 mL dextrose 5% in water. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Let’s calculate the IV pump rate for administering dobutamine to a preterm newborn.
Step 1 is to convert the dose from mcg/kg/min to mg/kg/min. We know that 1 mg = 1000 mcg, so we have:
12 mcg/kg/min ÷ 1000 = 0.012 mg/kg/min
Step 2 is to calculate the total amount of dobutamine the newborn needs per minute:
0.012 mg/kg/min × 2 kg = 0.024 mg/min
Step 3 is to convert this to an hourly rate:
0.024 mg/min × 60 min/hr = 1.44 mg/hr
Step 4 is to calculate the volume of the solution that contains this amount of dobutamine. We know that 250 mg of dobutamine is dissolved in 500 mL of solution, so:
(1.44 mg/hr ÷ 250 mg) × 500 mL = 2.88 mL/hr
So, the nurse should set the IV pump to deliver approximately 2.9 mL/hr (rounded to the nearest tenth).
A nurse is preparing to administer 2.5 L of lactated Ringer's to a client. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Step 1: Convert liters to milliliters.
1 liter is equal to 1000 milliliters. Therefore, we can convert 2.5 liters to milliliters as follows:
2.5 liters * 1000 milliliters/liter = 2500 milliliters
Step 2: Round the answer to the nearest whole number.
The answer is 2500 milliliters. Since we are instructed to round to the nearest whole number, we do not need to make any changes.
Therefore, the nurse should administer 2500 mL of lactated Ringer's to the client.
A nurse is preparing to administer medroxyprogesterone 150 mg IM to a client who has requested contraception. Available is medroxyprogesterone solution for injection 150 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Dosage (mL) = Ordered dose (mg) / Available dose (mg/mL) Therefore;
Dosage = 150 mg / 150 mg/mL Dosage = 1 mL
Therefore, the nurse should administer 1 mL of medroxyprogesterone solution for injection to the client.
A nurse is preparing to administer cephalexin 500 mg PO every 6 hr to an antepartum client who has a urinary tract infection. Available is cephalexin 250 mg tablets. How many tablets should the nursing staff administer in a 24-hour period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Number of tablets = (Dose per administration x Number of administrations per day) / Tablet strength
Number of tablets = (500 mg x 4) / 250 mg
Number of tablets = 2000 mg / 250 mg Number of tablets = 8
Therefore, the nursing staff should administer 8 tablets in a 24hrs.
A nurse is preparing to administer acetaminophen 56 mg PO to a newborn. Available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Dose = Desired dose / Available dose x Volume Therefore;
Dose = (56 mg / 160 mg) x 5 mL Therefore;
Dose = 0.35 x 5 mL Dose = 1.75 mL
Round to the nearest tenth: Dose = 1.8 mL
The nurse should administer 1.8 mL
A nurse is preparing to administer ketorolac 15 mg IM every 6 hr PRN for pain to a client who is postoperative following a cesarean birth and reports pain. Available is ketorolac injection 30 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Volume = Dose / Concentration Volume = 15 mg / 30 mg/mL
Volume = 0.5 mL
A nurse is preparing to administer nitroprusside 2 mcg/kg/min via continuous IV infusion to a client who weighs 75 kg. Available is nitroprusside 50 mg in dextrose 5% in water 250 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate in mL/h = Dose (mcg/kg/min) x Weight (kg) x 60 / Concentration (mcg/mL) In this case, the dose is 2 mcg/kg/min and the concentration is 50 mg/250 mL or 200 mcg/mL. Therefore, the infusion rate is:
Infusion rate (mL/h) = 2 x 75 x 60 / 200 Infusion rate (mL/h) = 45
The nurse should set the IV pump to deliver 45 mL/h.
A nurse is preparing to administer dopamine 5 mcg/kg/min via continuous IV infusion to a newborn who weighs 4.4 kg and has septic shock. Available in dopamine 200 mg in dextrose 5% in water 250 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
The dose of dopamine in mg/hr: 5 mcg/kg/min x 4.4 kg x 60 min/hr = 1320 mcg/hr Converted to mg: 1320 mcg/hr / 1000 mcg/mg = 1.32 mg/hr
Infusion rate in mL/hr: 1.32 mg/hr / (200 mg/250 mL) = 1.65 mL/hr Rounded off to the nearest tenth: 1.7 mL/hr
A nurse is preparing to administer magnesium sulfate 4 g to a client by intermittent IV bolus over 20 min. Available is magnesium sulfate 4 g in 0.9% sodium chloride 50 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate = volume in mls/ infusion time in hrs
= 50mls divided by 20/60
= 150mls/hr
The nurse should set the IV pump to deliver 150 mL/hr.
A nurse is preparing to administer nitroprusside 2 mcg/kg/min via continuous IV infusion to a client who weighs 75 kg. Available is nitroprusside 50 mg in dextrose 5% in water 250 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Pump rate in mL/hour = Dose (mcg/kg/min) x Weight (kg) x 60 / Concentration (mcg/mL)
The concentration of nitroprusside is given as 50 mg in 250 mL of dextrose 5% in water.
Convert this to mcg/mL; multiply by 1000
Concentration (mcg/mL) = 50 mg x 1000 / 250 mL = 200 mcg/mL Therefore;
Pump rate in mL/hour = 2 mcg/kg/min x 75 kg x 60 / 200 mcg/mL Pump rate in mL/hour = 45 mL/hour
Therefore, the nurse should set the IV pump to deliver 45 mL/hour
A nurse is preparing to administer lidocaine 1.7 mg/min via continuous IV infusion to a client who is pregnant and has a ventricular arrhythmia. Available is lidocainePrepared by Dr Brandel Andove1 g in dextrose 5% in water 250 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
1.7mg/min = 1.7*60 = 102mg/hr 1g=1000mg
1000mg= 250mls of lidocaine dextrose 102mg = 102*250/1000 = 25.5ml/hr
Rounded off to the nearest whole number, the pump should be set deliver 26 mL/hr.
A nurse is reviewing a prescription to initiate an infusion of terbutaline at 2.5 mcg/min to a client PRN more than four uterine contractions in 1 hr and to increase the infusion by 5 mcg/min every 10 min until contractions stop, not to exceed a rate of 30 mcg/min. How should the nurse interpret this prescription?
Explanation
by 5 mL/hr when titrating the dosage. This is because terbutaline is a beta-2 agonist that relaxes the smooth muscles of the uterus and bronchi. It is
administered as a continuous infusion of a solution containing 3-5 mcg/mL of terbutaline. Therefore, increasing the infusion rate by 5 mcg/min every 10 min means increasing the drip rate by 5 mL/hr, assuming a drop factor of 60 drops/mL. The other options are incorrect because:
Choice A is wrong because The maximum rate of terbutaline infusion is 30 mcg/min, which corresponds to 18 mL/hr, not 18 mg/hr;
Choice B is wrong because The rate of terbutaline infusion is not based on the client's weight, but on the number and frequency of uterine contractions; Choice D is wrong since The nurse should initiate the infusion of terbutaline if the client has more than four contractions in 1 hr, not five or more.
A nurse is preparing to administer magnesium sulfate 4 g to a client by intermittent IV bolus over 20 min. Available is magnesium sulfate 4g in 0.9% sodium chloride 50 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Infusion rate= volume of infusion/ time in hours 50 divided by 20/60 = 150mls/hr
A nurse is preparing to administer procaine penicillin G 800,000 units IM. Available is procaine penicillin G Injection 600,000 units/mL. How many mi should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Amount (mL) = Dose (units) / Concentration (units/mL) Substitute the given values into the formula:
Amount (mL) = 800,000 units / 600,000 units/mL Amount (mL) = 1.3 mL
Therefore, the nurse should administer 1.3 mL of procaine penicillin G injection
A nurse is preparing to administer heparin 1,000 units/hr via continuous IVinfusion to a client. Available is heparin 25,000 units in 0.9% sodium chloride 250 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
IV pump rate (mL/hr) = (units/hr x volume) / total units
In this case, the units/hr is 1,000, the volume is 250 mL, and the total units is 25,000. IV pump rate (mL/hr) = (1,000 x 250) / 25,000
Therefore;
IV pump rate (mL/hr) = 250,000 / 25,000 IV pump rate (mL/hr) = 10
Therefore, the nurse should set the IV pump to deliver 10 mL/hr.
Introduction
A nurse is caring for a newborn who exhibits signs of hypotonicity, weak reflexes, and a weak cry.
Explanation
Hypoglycemia is a condition where the blood glucose level is too low, which can affect the brain and nervous system function.Hypoglycemia can cause symptoms such as hypotonia (low muscle tone), weak reflexes, and a weak cry in newborns.
These symptoms are due to the lack of energy supply to the muscles and nerves.
Choice B. Hyperbilirubinemia is wrong because it is a condition where the blood level of bilirubin, a waste product from red blood cell breakdown, is too high.
Hyperbilirubinemia can cause jaundice (yellowing of the skin and eyes), but not hypotonia, weak reflexes, or a weak cry.
Choice C. Preterm birth is wrong because it is a condition where the baby is born before 37 weeks of gestation.
Preterm birth can cause many complications, such as respiratory distress, bleeding in the brain, and infection, but not hypotonia, weak reflexes, or a weak cry.
Choice D. Macrosomia is wrong because it is a condition where the baby is larger than average at birth, usually weighing more than 4 kg (8 lb 13 oz).
Macrosomia can cause problems during delivery, such as shoulder dystocia, birth injury, and low blood sugar, but not hypotonia, weak reflexes, or a weak cry.
A nurse is assessing a newborn who appears wasted, with peely, cracked, and leathery skin.
This presentation is consistent with:.
Explanation
This presentation is consistent with a newborn who has been in the womb for longer than 42 weeks.Post-term newborns often have dry, peeling, loose skin and may appear abnormally thin.They may also have overgrown nails and large amount of hair on the head.
Choice A is wrong because preterm birth is associated with low birth weight, immature skin, and lanugo (fine hair) on the body.
Choice B is wrong because macrosomia is a condition where the newborn is significantly larger than average, usually due to maternal diabetes or obesity.
Choice C is wrong because hyperbilirubinemia is a condition where the newborn has high levels of bilirubin in the blood, causing jaundice (yellowing of the skin and eyes).
A nurse is caring for a newborn with elevated serum bilirubin levels and jaundice.
The nurse suspects that the newborn is experiencing:.
Explanation
The correct answer is choice B. Pathologic jaundice.Pathologic jaundice is a type of jaundice that occurs due to an underlying health problem, such as blood group incompatibility, infection, liver disease, or enzyme deficiency.
Pathologic jaundice usually appears within the first 24 hours of life and can cause severe complications if not treated promptly.
Choice A is wrong because physiologic jaundice is a normal and common condition that occurs in most newborns due to the immaturity of their liver and the high turnover of red blood cells.Physiologic jaundice usually appears between the second and fourth day after birth and resolves within one to two weeks without treatment.
Choice C is wrong because hypoglycemia is a low blood sugar level that can cause symptoms such as jitteriness, poor feeding, lethargy, and seizures in newborns.Hypoglycemia is not directly related to bilirubin levels or jaundice, although some conditions that cause hypoglycemia, such as prematurity or infection, can also increase the risk of jaundice.
Choice D is wrong because preterm birth is a risk factor for jaundice, not a cause of it.Preterm babies have higher bilirubin levels because their liver is less developed and their red blood cells have a shorter lifespan than term babies.
Preterm birth can also be associated with other causes of pathologic jaundice, such as infection or hemolysis (breakdown of red blood cells)
A client is concerned about their newborn's risk for respiratory distress.
The nurse explains that the highest risk for respiratory distress is seen in:.
Explanation
Preterm infants are at the highest risk for respiratory distress syndrome (RDS), a common breathing disorder that affects newborns.RDS occurs because of a lack of surfactant, a foamy substance that keeps the lungs fully expanded.Surfactant is usually produced by the lungs during the third trimester of pregnancy, which starts after the 26th week.Therefore, babies born before their due date, especially before 28 weeks of pregnancy, are more likely to have RDS.
Choice B is wrong because macrosomic babies, or babies who are larger than average at birth, are not at increased risk for RDS.
However, they may have other complications such as birth injuries or low blood sugar levels.
Choice C is wrong because post-term infants, or babies who are born after 42 weeks of pregnancy, are not at increased risk for RDS.
However, they may have other complications such as meconium aspiration or low blood sugar levels.
Choice D is wrong because newborns with hyperbilirubinemia, or high levels of bilirubin in the blood, are not at increased risk for RDS.
However, they may have other complications such as jaundice or brain damage.
Other risk factors for RDS include being a white male, having multiple fetuses, having a mother with diabetes, and having premature rupture of membranes (PROM).
A client asks the nurse about the main complication associated with untreated hyperbilirubinemia.
The nurse explains that untreated hyperbilirubinemia can lead to:.
Explanation
The correct answer is choice A. Cerebral palsy.
Hyperbilirubinemia is a condition where there is too much bilirubin in the blood.
Bilirubin is a yellow pigment that is produced when red blood cells break down.
Normally, the liver processes bilirubin and excretes it in bile.
However, if the liver is immature or damaged, or if there is excessive hemolysis of red blood cells, bilirubin can accumulate in the blood and cause jaundice.
If the bilirubin level is very high, it can cross the blood-brain barrier and damage the brain cells, leading to a condition called kernicterus.
Kernicterus can cause cerebral palsy, which is a group of disorders that affect movement and posture.
Choice B. Hypoglycemia is wrong because it is a condition where the blood glucose level is too low.
It can be caused by many factors, such as inadequate intake, excessive insulin or oral hypoglycemic agents, infection, stress, or exercise.
Hypoglycemia can cause symptoms such as sweating, trembling, hunger, confusion, dizziness, or seizures.
It can be treated by giving glucose orally or intravenously.
Choice C. Necrotizing enterocolitis is wrong because it is a condition where the intestinal tissue becomes inflamed and dies.
It can affect premature infants or infants with low birth weight, congenital heart disease, or sepsis.
Necrotizing enterocolitis can cause symptoms such as abdominal distension, bloody stools, vomiting, lethargy, or shock.
It can be treated by stopping enteral feeding, giving antibiotics, and providing supportive care.
In severe cases, surgery may be needed to remove the necrotic tissue.
Choice D. Hypotonicity is wrong because it is a condition where the muscle tone is abnormally low.
It can be caused by many factors, such as nerve damage, spinal cord injury, brain injury, genetic disorders, or electrolyte imbalance.
Hypotonicity can cause symptoms such as weakness, flaccidity, poor posture, or difficulty swallowing.
It can be treated by physical therapy, braces, splints, or medication.
Hypoglycemia
A nurse is assessing a newborn who is displaying jitteriness, poor feeding, and seizures.
The nurse suspects the newborn is experiencing:.
Explanation
The correct answer is choice B. Hypoglycemia.Hypoglycemia is a condition where the blood sugar level is too low, which can affect the brain function and cause symptoms such as jitteriness, poor feeding, and seizures.Hypoglycemia is common in newborns, especially in preterm, small for gestational age, and infants of diabetic mothers.
Choice A is wrong because hyperglycemia is a condition where the blood sugar level is too high, which can cause dehydration, increased urination, and ketoacidosis.Hyperglycemia does not usually cause seizures in newborns.
Choice C is wrong because hypertension is a condition where the blood pressure is too high, which can cause damage to the blood vessels and organs.Hypertension can cause seizures in older children and adults, but it is rare in newborns.
Choice D is wrong because hypocalcemia is a condition where the calcium level in the blood is too low, which can affect the nerve and muscle function and cause symptoms such as twitching, spasms, and tetany.Hypocalcemia can also cause seizures in newborns, but it is less common than hypoglycemia.
A client with diabetes gives birth to a premature newborn.
The nurse should anticipate that the newborn is at risk for:.
Explanation
The correct answer is choice B. Hypoglycemia.
The newborn is at risk for hypoglycemia because of the maternal diabetes and the prematurity.Maternal diabetes causes fetal hyperinsulinism, which persists after birth and lowers the blood glucose level of the newborn.Prematurity causes inadequate glycogen stores and immature enzyme function, which also contribute to hypoglycemia.Hypoglycemia can cause symptoms such as tachycardia, cyanosis, seizures, and apnea.
Choice A is wrong because hyperglycemia is unlikely in a newborn with hyperinsulinism and deficient glycogen stores.
Choice C is wrong because hypertension is not a common complication of maternal diabetes or prematurity in newborns.
Choice D is wrong because hypothyroidism is not related to maternal diabetes or prematurity.Hypothyroidism can cause symptoms such as lethargy, poor feeding, jaundice, and hypotonia.
Normal ranges for blood glucose levels in newborns vary depending on the age, weight, and feeding status of the baby.
Generally, a level below 40 mg/dL (2.2 mmol/L) in symptomatic term newborns, below 45 mg/dL (2.5 mmol/L) in asymptomatic term newborns between 24 hours and 48 hours of life, or below 30 mg/dL (1.7 mmol/L) in preterm newborns in the first 48 hours is considered hypoglyc
A nurse is caring for a newborn who was born to a mother with diabetes mellitus.
The nurse should monitor the newborn for which of the following signs of hypoglycemia?
Explanation
The correct answer is choice A. Jitteriness.Jitteriness or tremors are the most common signs of hypoglycemia in a newborn baby.
Hypoglycemia is when the level of sugar (glucose) in the blood is too low.
Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can happen for many reasons, such as poor nutrition for the mother during pregnancy, making too much insulin because the mother has diabetes, or not enough oxygen at birth.
Choice B. Tachycardia is wrong because it is not a typical sign of hypoglycemia in a newborn baby.
Tachycardia is a fast heart rate that can be caused by other conditions, such as fever, infection, or dehydration.
Choice C. Hyperthermia is wrong because it is not a sign of hypoglycemia in a newborn baby.
Hyperthermia is a high body temperature that can be caused by overheating, infection, or inflammation.Hypoglycemia can cause low body temperature (hypothermia), not high body temperature.
Choice D. Hypertonia is wrong because it is not a sign of hypoglycemia in a newborn baby.
Hypertonia is increased muscle tone or stiffness that can be caused by brain damage, nerve damage, or genetic disorders.Hypoglycemia can cause weak or floppy muscles (poor muscle tone), not increased muscle tone.
A nurse is assessing a newborn who has intrauterine growth restriction (IUGR).
The nurse should recognize that this newborn is at risk for developing hypoglycemia because of which of the following factors?
Explanation
The correct answer is choice C. Increased insulin production.Infants with intrauterine growth restriction (IUGR) are at risk for hypoglycemia due to poor nutrient reserves and hyperinsulinism.
Hyperinsulinism is a condition where the pancreas produces too much insulin, which lowers the blood glucose level.Infants with IUGR may have hyperinsulinism because of placental insufficiency, maternal diabetes, or fetal stress.
Choice A is wrong because increased glycogen stores would protect against hypoglycemia, not cause it.
Glycogen is a form of stored glucose that can be broken down when blood glucose level is low.
Choice B is wrong because decreased gluconeogenesis would also protect against hypoglycemia, not cause it.
Gluconeogenesis is a process where the liver makes glucose from non-carbohydrate sources, such as amino acids or lactate.
Choice D is wrong because decreased glucose consumption would also protect against hypoglycemia, not cause it.
Glucose consumption is the rate at which cells use glucose for energy production.
If glucose consumption is low, blood glucose level would be high.
A nurse is performing a heel stick blood glucose test on a newborn who is preterm.
The nurse should apply a heel warmer to the newborn’s foot before obtaining the blood sample for which of the following reasons?
Explanation
The correct answer is choice B. To increase blood flow.A heel warmer is applied to the newborn’s foot before obtaining the blood sample to increase the blood flow to the area and make it easier to collect the sample.A heel warmer can also reduce pain and bruising by dilating the blood vessels and reducing the need for multiple punctures.
Choice A is wrong because a heel warmer does not prevent infection.Infection prevention requires proper cleaning of the puncture site and disposal of the lancet.
Choice C is wrong because a heel warmer does not reduce pain by itself.Pain reduction requires other measures such as cuddling, feeding, and distraction.
Choice D is wrong because a heel warmer does not prevent bruising.Bruising prevention requires applying pressure to the puncture site after collecting the sample.
Normal ranges for blood glucose levels in newborns vary depending on the method of measurement, but generally they are between 2.6 and 6.0 mmol/L.
A nurse is reviewing the laboratory results of a pregnant client.
Which finding would be considered abnormal regarding hCG levels?
Explanation
Decreased hCG levels are abnormal regarding hCG levels in pregnancy.hCG is a hormone that plays an important role in pregnancy, and levels can vary widely at this time and between individuals.However, during early pregnancy, hCG levels typically double every two to three days.Low or declining hCG levels can signal a problem with the pregnancy, such as an impending miscarriage or ectopic pregnancy.
Choice B is wrong because unchanged hCG levels are also abnormal regarding hCG levels in pregnancy.
As mentioned above, hCG levels should increase rapidly during the first few weeks of pregnancy.
Choice C is wrong because increased hCG levels are normal regarding hCG levels in pregnancy.Levels of hCG can vary widely from one pregnant woman to another, but they generally peak at around 8 to 14 weeks after conception.
Choice D is wrong because increased prolactin levels are not related to hCG levels in pregnancy.
Prolactin is another hormone that stimulates milk production in the breasts.
Prolactin levels rise during pregnancy and breastfeeding, but they do not affect hCG levels.
A nurse is teaching a pregnant client about nutrition during pregnancy and lactation.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
I will need to increase my protein intake by 25 g per day while I am pregnant.” Protein is essential for the growth and development of the fetus and the placenta, as well as for the increased blood volume and maternal tissues.
The recommended dietary allowance (RDA) for protein during pregnancy is 71 g per day, which is 25 g more than the RDA for non-pregnant women.
Choice B is wrong because the calcium intake does not need to increase during lactation.
The RDA for calcium for lactating women is the same as for non-lactating women, which is 1000 mg per day for women aged 19 to 50 years.
Calcium absorption and retention are enhanced during lactation, and bone loss that may occur is usually reversible after weaning.
Choice C is wrong because the calorie intake does not need to increase by 500 kcal per day during the third trimester.
The estimated energy requirement (EER) for pregnant women increases by 340 kcal per day in the second trimester and by 452 kcal per day in the third trimester.
However, these values may vary depending on the pre-pregnancy weight, activity level, and rate of weight gain of the individual woman.
Choice D is wrong because the iron intake needs to increase by more than 10 mg per day while pregnant.
The RDA for iron during pregnancy is 27 mg per day, which is 9 mg more than the RDA for non-pregnant women.
However, this amount may not be enough to prevent iron deficiency anemia in some pregnant women, especially those who start pregnancy with low iron stores or have high iron losses due to bleeding or multiple pregnancies.
Therefore, iron supplements are often recommended for pregnant women, especially in the second and third trimesters.
A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?
Explanation
nswer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.
Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.
A nurse is caring for a client who has diabetic ketoacidosis and is receiving intravenous fluids. Which of the following electrolytes should the nurse monitor closely for signs of imbalance? (Select all that apply.)
Explanation
Choice A reason:
Chloride is not a major electrolyte that is affected by diabetic ketoacidosis (DKA) Chloride levels may be low, normal or high depending on the acid-base status and hydration of the client. Therefore, chloride is not a priority electrolyte to monitor for signs of imbalance.
Choice B reason:
Phosphate is also not a major electrolyte that is affected by DKA. Phosphate levels may be low due to insulin therapy or high due to renal impairment, but these are not directly related to DKA. Therefore, phosphate is not a priority electrolyte to monitor for signs of imbalance.
Choice C reason:
Bicarbonate is a major electrolyte that is affected by DKA. Bicarbonate levels are low in DKA due to metabolic acidosis caused by the accumulation of ketones in the blood. Low bicarbonate levels can lead to symptoms such as nausea, vomiting, abdominal pain, confusion and coma. Therefore, bicarbonate is a priority electrolyte to monitor for signs of imbalance.
Choice D reason:
Sulfate is not a major electrolyte that is affected by DKA. Sulfate levels are not routinely measured in clinical practice and have no significant role in DKA. Therefore, sulfate is not a priority electrolyte to monitor for signs of imbalance.
Choice E reason:
Potassium is a major electrolyte that is affected by DKA. Potassium levels can be high or low in DKA depending on several factors such as insulin therapy, fluid replacement, renal function and acid-base status. High or low potassium levels can cause cardiac arrhythmias, muscle weakness, paralysis and respiratory failure. Therefore, potassium is a priority electrolyte to monitor for signs of imbalance.
The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? (Select all that apply.).
No explanation
The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.)
No explanation
Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):.Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):
No explanation
Which data would be included in a health history? (Select all that apply.)
No explanation
Preterm birth
A nurse is assessing a preterm infant who has necrotizing enterocolitis (NEC).
Which of the following findings should alert the nurse to a possible bowel perforation?
Explanation
All of these findings can indicate a possible bowel perforation in a preterm infant with necrotizing enterocolitis (NEC).NEC is a serious condition that causes inflammation and necrosis of the intestinal tissue, and can lead to a hole (perforation) in the bowel wall.Bacteria can leak through this hole and cause infection and sepsis.NEC usually develops within two to six weeks after birth, and mostly affects premature babies.
Choice A is wrong because bloody stools are not specific for bowel perforation.They can also be seen in mild cases of NEC or other causes of gastrointestinal bleeding.
Choice B is wrong because abdominal distension is a common sign of NEC, but not necessarily of bowel perforation.It can be caused by gas accumulation, fluid retention, or inflammation of the bowel wall.
Choice C is wrong because bilious vomitus is also a non-specific sign of NEC or other causes of bowel obstruction.It can indicate a problem with the passage of food or bile through the intestines.
A nurse is measuring the head circumference of a preterm infant.
Which of the following methods should the nurse use to ensure accuracy?
Explanation
This is the recommended method for measuring the head circumference of a preterm infant.
It ensures accuracy by capturing the largest dimension of the head, which reflects the growth of the brain.
Choice B is wrong because it does not measure the widest part of the head, which may be above or below the occiput.
Choice C is wrong because it does not measure the widest part of the head, which may be above or below the ears.
Choice D is wrong because it does not measure the widest part of the head, which may be above or below the chin.
The normal range for head circumference at birth for preterm infants born between 32 and 42 weeks gestation is about 25 to 36 cm.Head circumference should be measured and plotted regularly until two years of age for preterm infants.
A nurse is educating the parents of a preterm infant who has retinopathy of prematurity (ROP).
Which of the following statements should the nurse include in the teaching?
Explanation
ROP is a condition that affects the blood vessels of the retina in premature infants.
It can cause vision loss or blindness if not treated.
The main treatment for ROP is laser therapy or cryotherapy to stop abnormal blood vessel growth.
However, these treatments do not restore normal vision and may have complications.
Therefore, regular eye exams are needed to monitor the condition and detect any changes or problems.
Choice B is wrong because surgery is not a common treatment for ROP.
Surgery may be done in some cases to reattach the retina if it detaches from the eye wall, but this is a rare and serious complication of ROP.
Choice C is wrong because oxygen therapy can actually worsen ROP.
High levels of oxygen can stimulate the abnormal blood vessel growth in the retina.
Oxygen therapy should be used with caution and only when necessary for premature infants.
Choice D is wrong because glasses do not improve vision in ROP.
Glasses can correct refractive errors such as nearsightedness or farsightedness, but they cannot fix the damage to the retina caused by ROP.
A nurse is providing developmental care for a preterm infant in the neonatal intensive care unit (NICU).
Which of the following interventions should the nurse implement?
Explanation
This is because preterm infants are born before or during critical periods of brain development and need to reduce stress and promote neurological development.Cluster care means grouping care activities together and timing them according to the infant’s cues, such as alertness, hunger, and sleepiness.This way, the infant can have longer periods of undisturbed sleep, which is essential for brain maturation.
Choice B is wrong because keeping the lights and noise level high can cause sensory overload and stress for the preterm infant.The NICU environment should be dimmed and quiet to mimic the womb and support the infant’s circadian rhythm.
Choice C is wrong because avoiding touching or holding the infant can deprive the infant of human contact and bonding, which are important for emotional and social development.Preterm infants can benefit from gentle touch, massage, and kangaroo care, which is holding the baby with direct skin-to-skin contact.These interventions can help with body temperature, breastfeeding, weight gain, and attachment.
Choice D is wrong because changing the infant’s position frequently can disrupt the infant’s sleep and cause stress.Preterm infants should be positioned in a way that supports their posture and alignment, such as flexion, midline orientation, and containment.Positioning aids such as blankets, rolls, or nests can be used to provide boundaries and comfort for the infant.
A nurse is evaluating a newborn who has hyperbilirubinemia and received phototherapy for 24 hours.
Which of the following outcomes indicates that phototherapy was effective?
Explanation
This indicates that phototherapy was effective because it lowers the level of bilirubin in the blood by converting it into a form that can be excreted in urine and stool.
Choice A is wrong because bronze discoloration of the skin is a side effect of phototherapy, not an outcome.
Choice C is wrong because increased urine output and specific gravity are signs of dehydration, which can occur with phototherapy due to insensible water loss.
Choice D is wrong because normal vital signs and neurological status do not reflect the effectiveness of phototherapy on bilirubin levels.
Normal ranges for serum bilirubin levels vary by age and risk factors, but generally they should be less than 15 mg/dL (257 μmol/L) for term newborns and less than 18 mg/dL (308 μmol/L) for preterm newborns.
Macrosomia
A nurse is caring for a newborn with macrosomia who was born vaginally with shoulder dystocia.
Which of the following assessments should the nurse perform to check for a possible brachial plexus injury?
Explanation
Observe the range of motion of the shoulders and arms.This is because a brachial plexus injury affects the nerve network that provides feeling and muscle control in the shoulder, arm, forearm, hand, and fingers.A baby with a brachial plexus injury may have full or partial lack of movement, a weakened grip, numbness, or an odd position of the affected arm.
Observing the range of motion of the shoulders and arms can help detect any signs of nerve damage or weakness.
Choice A is wrong because palpating the clavicles for crepitus or deformity is a way to check for a possible clavicular fracture, not a brachial plexus injury.
Choice C is wrong because measuring the head circumference and comparing it with the chest circumference is a way to check for a possible cephalopelvic disproportion (CPD), not a brachial plexus injury.
Choice D is wrong because auscultating the lungs for crackles or wheezes is a way to check for a possible respiratory distress, not a brachial plexus injury.
A nurse is teaching a pregnant client who has diabetes mellitus about the risk of having a baby with macrosomia.
Which of the following statements by the client indicates a need for further teaching?
Explanation
“I should expect to have a cesarean section because vaginal delivery is too risky.” This statement indicates a need for further teaching because it is not true that all women with diabetes mellitus and macrosomia need to have a cesarean section.
The mode of delivery depends on several factors, such as the estimated fetal weight, the maternal pelvic size, the fetal position, and the presence of any complications.
The nurse should explain to the client that vaginal delivery may be possible if the conditions are favorable and the risks are low.
Choice A is wrong because it is a correct statement.
Women with diabetes mellitus should monitor their blood glucose levels closely and follow their prescribed diet to prevent hyperglycemia and fetal macrosomia.
Choice B is wrong because it is also a correct statement.
Women with diabetes mellitus and macrosomia should have regular prenatal visits and ultrasounds to monitor their baby’s growth and well-being.
Choice D is wrong because it is another correct statement.
Women with diabetes mellitus and macrosomia should be aware of the signs of hypoglycemia in their baby after birth, such as jitteriness, lethargy, poor feeding, and low temperature.
The baby may need glucose supplementation or intravenous fluids to maintain normal blood glucose levels.
Normal ranges:
• Blood glucose levels: 70-110 mg/dL (3.9-6.1 mmol/L) for fasting; <140 mg/dL (<7.8 mmol/L) for postprandial
• Estimated fetal weight: 2500-4000 g (5.5-8.8 lb) for term
A nurse is reviewing the laboratory results of a newborn with macrosomia who has polycythemia.
Which of the following findings should the nurse expect?
Explanation
A hematocrit of 75% indicates polycythemia, which is a condition of having too many red blood cells.Polycythemia is a common complication of macrosomia, which is a condition of having a birth weight of more than 8 pounds, 13 ounces.Polycythemia can cause problems such as jaundice, seizures, and organ dysfunction.
Choice B is wrong because a hemoglobin of 12 g/dL is within the normal range for a newborn, which is 14 to 24 g/dL.
Choice C is wrong because a platelet count of 150,000/mm3 is within the normal range for a newborn, which is 150,000 to 450,000/mm3.
Choice D is wrong because a white blood cell count of 9,000/mm3 is within the normal range for a newborn, which is 9,000 to 30,000/mm3.
A nurse is preparing to administer phototherapy to a newborn with macrosomia who has hyperbilirubinemia.
Which of the following interventions should the nurse include in the plan of care?
Explanation
Cover the newborn’s eyes with eye shields or patches.This is because phototherapy exposes the newborn to high-intensity light that can damage the retina and cause eye irritation.Eye shields or patches should be removed every 4 hours to check for eye infection, injury, or displacement.
Choice B is wrong because sunscreen lotion can block the effect of phototherapy and increase the risk of skin irritation and infection.The newborn’s skin should be exposed as much as possible to the light source.
Choice C is wrong because feeding the newborn every 4 hours is not enough to prevent dehydration.Phototherapy can increase insensible water loss and fluid requirements.The newborn should be fed every 2 to 3 hours or on demand, and the urine output and weight should be monitored closely.
Choice D is wrong because turning off the phototherapy lights during blood draws can reduce the efficacy of the treatment and prolong the duration of exposure.The lights should be turned off only when absolutely necessary, such as during physical examination or parental bonding.
A nurse is feeding a newborn with macrosomia who has hypoglycemia.
Which of the following actions should the nurse take?
Explanation
Feed the newborn formula or breastmilk as prescribed.This is because newborns with macrosomia (large birth weight) are at risk of hypoglycemia (low blood sugar) due to increased insulin production in response to high glucose levels in the womb.Formula or breastmilk provide adequate glucose and nutrients to prevent or treat hypoglycemia.
Choice B is wrong because glucose water does not provide enough calories or protein for growth and development.
Choice C is wrong because honey or corn syrup can cause infant botulism, a serious infection that affects the nervous system.
Choice D is wrong because rice cereal or oatmeal are not appropriate for newborns, as they can cause choking, allergies, or overfeeding.
Normal ranges for blood glucose levels in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).Newborns with a suspected or confirmed genetic hypoglycemia disorder have a lower threshold of 70 mg/dL (3.9 mmol/L).
Post-term birth
A nurse is caring for a post-term newborn who has meconium staining on the nails and umbilical cord.
What is the most likely cause of this finding?
Explanation
The newborn experienced fetal distress.Meconium staining is often caused by fetal hypoxia or other physiologic stress that triggers the fetus to pass meconium into the amniotic fluid before delivery.If the fetus aspirates the meconium, it can cause lung injury and respiratory distress, termed meconium aspiration syndrome.
Choice A is wrong because a bowel obstruction would not cause meconium staining of the nails and umbilical cord.
Choice B is wrong because a congenital anomaly would not necessarily cause meconium passage or staining.
Choice D is wrong because an infection may cause fetal distress, but it is not the direct cause of meconium staining.Meconium staining may be a sign of infection in the newborn.
A nurse is assessing a post-term newborn who has oligohydramnios.
What is the main complication associated with this condition?
Explanation
Oligohydramnios is a condition where there is too little amniotic fluid surrounding the fetus.
This can cause the umbilical cord to become compressed by the fetal body parts or the uterine wall, reducing blood flow and oxygen to the fetus.
This can lead to fetal distress, hypoxia, and acidosis.
Choice B is wrong because fetal malposition is not directly caused by oligohydramnios.
Fetal malposition is when the fetus is in an abnormal position for delivery, such as breech, transverse, or face presentation.
This can increase the risk of complications during labor and delivery, such as cord prolapse, dystocia, or birth trauma.
Choice C is wrong because placental abruption is not directly caused by oligohydramnios.
Placental abruption is when the placenta separates from the uterine wall before delivery, causing bleeding and reduced blood flow to the fetus.
This can be triggered by trauma, hypertension, or cocaine use.
Choice D is wrong because premature rupture of membranes (PROM) is not directly caused by oligohydramnios.
PROM is when the amniotic sac breaks before the onset of labor, causing leakage of fluid and increased risk of infection.
This can be caused by infection, cervical incompetence, or mechanical factors.
A nurse is preparing to perform a heel stick blood glucose test on a post-term newborn who has macrosomia.
What is the rationale for this test?
Explanation
A post-term newborn who has macrosomia is at risk of hypoglycemia because the fetus produces more insulin in response to the high glucose levels from the mother.
After birth, the glucose supply from the mother is cut off, but the newborn still has high insulin levels, which can cause low blood glucose.
A heel stick blood glucose test is done to monitor the newborn’s blood glucose level and prevent complications from hypoglycemia.
Choice B is wrong because hyperglycemia is not a common problem for post-term newborns with macrosomia.
Hyperglycemia occurs when there is too much glucose and not enough insulin in the blood.
This is more likely to happen in infants of diabetic mothers who have poor glycemic control during pregnancy.
Choice C is wrong because polycythemia is not related to insulin or glucose levels.
Polycythemia is a condition where there are too many red blood cells in the blood, which can cause increased blood viscosity and clotting.
This can happen in post-term newborns due to chronic hypoxia in utero, which stimulates erythropoietin secretion.
Choice D is wrong because anemia is not related to insulin or glucose levels.
Anemia is a condition where there are not enough red blood cells or hemoglobin in the blood, which can cause decreased oxygen delivery to the tissues.
This can happen in newborns due to blood loss, hemolysis, or decreased production of red blood cells.
The normal range for blood glucose in newborns is 40 to 80 mg/dL (2.2 to 4.4 mmol/L).
A heel stick blood glucose test should be done within the first hour of life and repeated as needed based on the results and clinical signs of hypoglycemia.
A nurse is educating the parents of a post-term newborn who has hyperbilirubinemia and requires phototherapy.
What should the nurse include in the teaching?
Explanation
This is because phototherapy exposes the newborn to intense light that can damage the eyes and skin, and also increases water loss through the skin.
Eye shields protect the eyes from the light and a diaper prevents overexposure of the genital area.The newborn should also be turned frequently to expose different parts of the body to light.
Choice A is wrong because exposing the newborn to sunlight is not an effective treatment for hyperbilirubinemia and can cause sunburn.Choice C is wrong because breast milk does not interfere with phototherapy and breastfeeding should be continued as normal.Choice D is wrong because blood tests are not needed every 12 hours, but only when indicated by the bilirubin level or risk factors.
Normal bilirubin levels vary by age, gestational age, and risk factors.The American Academy of Pediatrics provides hour-specific nomograms for initiating phototherapy based on these factors.
A nurse is reviewing the laboratory results of a post-term newborn who has polycythemia and hypoxemia.
What is the most likely hematocrit value for this newborn?
Explanation
A hematocrit value of 65% indicates polycythemia, which is an abnormally high number of red blood cells.
Polycythemia can occur in post-term newborns who have hypoxemia, which is a low level of oxygen in the blood.Hypoxemia stimulates the production of erythropoietin, a hormone that increases red blood cell formation.
Choice A.35% is wrong because it is below the normal range for newborns, which is 45% to 61%.
A hematocrit value of 35% would indicate anemia, which is a low number of red blood cells.
Choice B.45% is wrong because it is at the lower end of the normal range for newborns.
A hematocrit value of 45% would not indicate polycythemia or hypoxemia.
Choice C.55% is wrong because it is within the normal range for newborns.
A hematocrit value of 55% would not indicate polycythemia or hypoxemia.
Hyperbilirubinemia
A nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy.
Which of the following actions should the nurse take?
Explanation
This is because phototherapy exposes the newborn to a special blue-to-green light that lowers the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.However, this light can also damage the newborn’s eyes and cause retinal injury or blindness, so it is important to protect them with a mask.
Choice A is wrong because applying lotion to the newborn’s skin before phototherapy can interfere with the light penetration and reduce the effectiveness of the treatment.
It can also cause skin irritation or allergic reactions.
Choice B is wrong because removing the newborn from phototherapy every 4 hours can interrupt the continuous exposure to the light and delay the reduction of bilirubin levels.
The newborn should only be removed from phototherapy for feeding, diaper changes, and physical examination.
Choice D is wrong because placing the newborn on a radiant warmer during phototherapy can increase the risk of dehydration, hyperthermia, and skin burns.
The newborn should be monitored for temperature and fluid balance during phototherapy and kept in a crib or bassinet with a blanket.
A nurse is assessing a newborn for signs of jaundice.
Which of the following methods should the nurse use to detect jaundice in the newborn?
Explanation
This method allows the nurse to detect jaundice by observing the color of the skin after applying and releasing pressure.
This is a simple and noninvasive way to check for jaundice in a newborn.
Choice A is wrong because palpating the newborn’s abdomen for hepatomegaly is not a reliable way to detect jaundice.Hepatomegaly is an enlargement of the liver that may indicate liver disease, but it is not specific to jaundice.
Choice B is wrong because measuring the newborn’s serum bilirubin level is not a method to detect jaundice, but rather to confirm and quantify it.
Serum bilirubin level is the amount of bilirubin in the blood, which is responsible for the yellow color of jaundice.A blood test is required to measure this level.
Choice D is wrong because observing the newborn’s urine and stool color is not a reliable way to detect jaundice.
The color of urine and stool may vary depending on the hydration status, feeding type and other factors of the newborn.Moreover, urine and stool color may not change until the bilirubin level is very high.
A nurse is teaching a parent about how to prevent physiologic jaundice in a breastfed newborn.
Which of the following instructions should the nurse include?