A level solution version 2025/2026
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus
who received NPH and regular humulin insulin at 7:30 a.m. At 11 a.m. the child
suddenly complains of dizziness, headache, and a shaky feeling. The nurse
immediately takes which action?
a. Contacts the physician
b. Gives the child milk to drink
c. Arranges to have the child's lunch tray delivered early
d. Prepares to administer intravenous 5% dextrose solution - correct answer B
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity.
Which is the first action on the part of the nurse?
a. Calling the physician
b. Inserting an oral airway
c. Turning the client on her side
d. Noting the time of the seizure - correct answer C
A nurse is preparing to administer an injection of vitamin K to a newborn. At which site
would the nurse select to administer the medication? - correct answer 3
The preferred injection site for the administration of vitamin K in the newborn is the
lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh).
This muscle is the preferred injection site because it is free of major blood vessels and
nerves and is large enough to absorb the medication
A nurse performs a bedside glucose test on a newborn infant whose mother has
diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would
take which action first?
Ask the mother to breastfeed the newborn
,Bottle-feed the newborn with diluted glucose
Start an intravenous line for the administration of glucose
Ask the laboratory to perform a blood glucose test immediately - correct answer D
Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298
mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported
and verified in the laboratory. Although feeding is an intervention, the result of a bedside
glucose must be verified by the laboratory. Some infants need IV glucose to maintain
glucose balance and prevent damage to the brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse
that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse
detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that
the umbilical cord is protruding from the vagina. Which actions should the nurse
perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
With two gloved fingers, exerting upward pressure, into the vagina, on the presenting
part
Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline
solution - correct answer A, C, D
Oxygen should be administered at 8-10 L/min via face mask
A nurse provides information to the mother of a child with diarrhea about signs and
symptoms that indicate the need to call the primary health care provider. Which
statement by the mother indicates the need for further instruction?
"I'll call the doctor if she gets dizzy and acts sick."
"I'll call the doctor if she has severe stomach cramps."
"I'll call the doctor if her temperature is 102°F (38.9°C) or higher."
"I'll call the physician if she goes longer than 6 hours without urinating." - correct
answer C
Call doctor at temperature above 100.
, A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux
(GER) would expect to note documentation of which other issue?
Refusal to suck
Frequent diarrhea
Recurrent otitis media
Inability to pass stools - correct answer C
Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from
pooling of secretions in the nasopharynx during sleep are characteristics of all types of
GER.
A nurse reviewing the record of a child with suspected acute poststreptococcal
glomerulonephritis notes that the child recently had a streptococcal throat infection that
was treated with antibiotics. Which diagnostic test will confirm the presence of acute
poststreptococcal glomerulonephritis does the nurse expect to find?
Throat culture
Blood urea nitrogen (BUN)
Antistreptolysin (ASO) titer
White blood cell (WBC) count - correct answer C
In caring for a child admitted to the hospital with Kawasaki disease, the nurse should
monitor the child most closely for signs which complication?
Anemia
Renal failure
Thrombus formation
Gastrointestinal disturbances - correct answer C
Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute
febrile exanthematous illness of children with a generalized vasculitis of unknown origin.