A newborn delivered via cesarean birth at 32 weeks to a mother who experienced placenta previa has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds
Which interventions are indicated for the care of this newborn? Select all that apply. 1. Start the infant on phototherapy.
2. Start the infant on iron supplements.
3. Have isotonic saline ready for transfusion.
4. Draw several vials of blood for laboratory testing.
5. Monitor the infant's cardiac and respiratory status.
6. Have O-negative packed red cells ready for a transfusion.
2, 5, 6
Explanation:
1. Phototherapy should only be started if the infant has jaundice.
2. Iron supplements should be given to help increase red blood cell production.
3. Isotonic saline transfusion is not used to treat anemia.
4. Blood draws should be kept to a minimum for clients with anemia.
5. This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment.
6. Clients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and cross-matched packed red cells should be used.
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When the patient enters into nephrotic syndrome after an exacerbation of glomerulonephritis, the nurse would expect to see:
a. decreased serum albumin. b. decreased lipids. c. decreased proteinuria. d. increased hematuria.
The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, "I just don't feel like going to work. I have no energy, and I can't eat or sleep." The patient shows no interest in taking part in his care
The nurse should a. Not be concerned about self-harm because the patient has not indicated any desire toward suicide. b. Ignore individual patient goals until the current crisis is over. c. Encourage the patient to purchase over-the-counter sleep aids to help him sleep. d. Assess the potential for suicide and make appropriate referrals.
After being diagnosed, a client asks the nurse "What is pyelonephritis?" The nurse should respond:
1. "Pyelonephritis is an infection of the bladder." 2. "Pyelonephritis is an infection of the urethra." 3. "Pyelonephritis is an infection of the prostate." 4. "Pyelonephritis is a common infection that needs to be treated to prevent complications."
A 3-year-old child presents with bruising on the legs and trunk and a petechial rash. The mother also reports frequent nosebleeds. Lab tests reveal a decreased platelet count. This symptomology supports which medical diagnosis?
a. Immune thrombocytopenic purpura (ITP) b. Leukemia c. Thalassemia d. Hemophilia