Four hours after the delivery of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?
a. Start an intravenous line with D5W
b. Notify the clinician stat
c. Document the event in the nurses' notes
d. Test for blood glucose level
D
It is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Test the blood glucose level according to agency's policy, treat symptoms with standing orders protocol, and notify the physician with the results. Permanent damage can occur if glucose is not constantly available to the brain. Documentation can wait until the infant has been tested and treated if there is a problem. These symptoms are signs of hypoglycemia in the newborn.
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A school-age child has begun to sleepwalk. What does the nurse advise the parents to perform?
a. Wake the child and help determine what is wrong. b. Leave the child alone unless he or she is in danger of harming him- or herself or others. c. Arrange for psychologic evaluation to identify the cause of stress. d. Keep the child awake later in the evening to ensure sufficient tiredness for a full night of sleep.
Identify an action that a school-age child would do to demonstrate concrete-operational development
1. A child follows the directions from the teacher to write his name on the board. 2. A child is playing dodgeball and decides to throw the ball at a person with a ball. 3. A child takes her friend's pencil because she wanted it. 4. A child is able to think through a math problem and check the work for a correct answer.
The nursing instructor teaches student nurses about the Food and Drug Administration (FDA) Pregnancy Categories. What should the nurse include?
A. Food and Drug Administration (FDA) Pregnancy Category C is safe to use during pregnancy. B. Food and Drug Administration (FDA) Pregnancy categories provide a framework for safe use of drugs in pregnant women. C. Food and Drug Administration (FDA) Pregnancy categories for individual drugs seldom change once they are established. D. Food and Drug Administration (FDA) Pregnancy categories are based on studies using clinical human research trials. E. Food and Drug Administration (FDA) Pregnancy Category X has been associated with teratogenic effects.
During an eye examination, a nurse notes that the client has mydriasis when:
a. The lens of each of the client's eyes is opaque. b. There is involuntary rhythmical, horizontal movement of the client's eyes. c. There is a white opaque ring encircling the client's limbus. d. The client's pupils are 7 mm and do not constrict.