A nurse is planning care for a newborn who is receiving phototherapy
for an elevated bilirubin level. Which of the following actions should
the nurse take? - ANS -D. Use a photometer to monitor the lamp's
energy
The nurse should monitor the lamp's energy throughout the therapy
to ensure the newborn is receiving the appropriate amount to be
effective.
A nurse is assessing a client at 34 weeks gestation who has a mild
placental abruption. Which of the following findings should the nurse
expect? - ANS -Dark red vaginal bleeding
,The nurse should expect this client with a mild placental abruption to
have minimal dark red vaginal bleeding.
A nurse is assessing a newborn and notes an axillary temperature of
96.9°F (36°C). Which of the following actions should the nurse
perform? - ANS -Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased
muscular and metabolic activity. This process increases glucose
consumption and puts the newborn at risk of hypoglycemia.
Incorrect Answers:
,A. The nurse should not obtain a rectal temperature from a newborn
due to the risk of rectal perforation. Instead, the nurse should obtain
an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be
bathed until the temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss
through convection. Additionally, there is a potential fire risk from the
bassinet linens and the vent.
A nurse is caring for a client who is in preterm labor and is receiving
magnesium sulfate. The client begins to show indications of
magnesium sulfate toxicity. Which of the following medications
should the nurse prepare to administer? - ANS -Correct Answer:
, C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion
immediately and prepare to administer calcium gluconate IV to
reverse the effects of magnesium sulfate and to prevent cardiac and
respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not
magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects
of magnesium sulfate.
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