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Exam (elaborations)

NR-452 Capstone Course Maternal_Newborn_Nursing_VATI_remediation

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Uploaded on
September 11, 2024
Number of pages
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Written in
2024/2025
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A nurse is caring for a client newly diagnosed with HIV. What vaccinations should the
nurse encourage the client to receive?
The nurse should encourage the client to receive hepatitis B, pneumococcal infection,
Haemophilus influenza type B, and viral influenza.
What is the priority interventions for respiratory depression for the newborn delivered 1
hour after the mother received a narcotic analgesic for labor pain?
The priority interventions for respiratory depression are:
 Support airway, breathing, and circulation (ABC’s)
 Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced
respiratory depression.
 In the event of distress, place newborn on mothers bare chest
What are manifestations of newborn hypoglycemia and what measures should the nurse
take if hypoglycemia occurs? Suggested Maternal Newborn Learning Activity:
Hypoglycemia in Newborn
Some of the manifestations of newborn hypoglycemia are:
Poor feeding, Jitteriness/tremors, hypothermia, diaphoresis, weak cry, lethargy, flaccid muscle
tone, seizures/coma, irregular respirations, cyanosis, and apnea.
Some of the measures that the nurse should take if hypoglycemia occurs are:
 An asymptomatic at-risk newborn who has a blood glucose level 25 mg/dL in the first 4
hr, or less than 35 mg/dL from 4 hr to 24 hr of age, should be offered oral feedings to
increase levels to greater than 45 mg/dL.
 Initiate IV dextrose for a symptomatic newborn.
 Provide frequent oral and/or gavage feedings or continuous parenteral nutrition early
after birth to treat hypoglycemia.
 Monitor the neonate’s blood glucose level closely per facility protocol.
 Monitor IV if the neonate is unable to feed orally.
A 6-week gestation client enters the emergency department with complaints for unilateral
stabbing pain and tenderness on the lower right abdominal quadrant and red vaginal
bleeding. The physician diagnoses the client with an ectopic pregnancy. The physician
orders methotrexate. What teaching should the nurse perform related to the administration
of methotrexate?
 Instruct the client who is taking methotrexate to avoid alcohol consumption and vitamins
containing folic acid to prevent a toxic response to the medication.
 Advise the client to protect herself from sun exposure (photosensitivity).
 Encourage the client and her partner to join pregnancy loss support group.




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