BSN HESI 366 – RN EXIT EXAM
(NIGHTINGALE COLLEGE, 2025–2026) –
VERIFIED QUESTIONS AND CORRECT
ANSWERS, GRADE A
NGN:A21800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2t
oA2aA2GA22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2Followin
gA2aA2spontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2
minuteA2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2and
A2appearsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat
.A2SheA2isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296
F,A2pulseA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2
mongolianA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
(TheA2dayA2shiftA2nurseA2reviewsA2theA2nursesA2notes,A2labs,A2andA2flowA2sheetA2fromA2th
eA2nightA2before.A2TheA2nurseA2plansA2onA2providingA2healthA2teachingA2forA2theA2clientA2a
ndA2herA2familyA2inA2preparationA2forA2discharge.)
ForA2eachA2teachingA2point,A2clickA2toA2indicateA2whetherA2itA2isA2indicatedA2orA2contraindi
cated.A2OnlyA2oneA2rightA2optionA2perA2row.
A)A2YouA2willA2needA2toA2seA2-A2Ans--A)
B)
C)
D)A2Indicated
E)
?????????
TheA2nurseA2isA2providingA2teachingA2toA2aA2clientA2withA2typeA22A2DMA2aboutA2importantA2
pointsA2forA2diseaseA2andA2symptomA2management.A2WhichA2statementA2byA2theA2clientA2
indicatesA2understanding?
A)A2UsingA2salt,A2herbs,A2andA2spicesA2willA2improveA2theA2flavorA2ofA2foods
B)A2GetA2anA2eyeA2examA2withA2anA2opthalmologistA2annually
C)A2ArrangeA2dietA2scheduleA2aroundA2threeA2regularA2mealsA2aA2day
D)A2InspectA2feetA2everyA2monthA2forA2ingrownA2nails,A2cuts,A2andA2calusesA2-A2Ans--
B)A2GetA2anA2eyeA2examA2withA2anA2opthalmologistA2annually
TheA2nurseA2isA2providingA2educationsA2toA2aA2clientA2whoA2experiencesA2recurrentA2level
sA2ofA2moderateA2anxietyA2toA2situationsA2andA2perceivedA2stress.A2InA2additionA2toA2infor
mationsA2aboutA2prescribedA2medicationsA2andA2administration,A2whichA2instructionA2sho
uldA2theA2nurseA2includeA2inA2theA2teaching?
A)A2CenterA2attentionA2onA2positiveA2upbeatA2music
B)A2FindA2outletsA2forA2moreA2socialA2interactionA2
,C)A2PracticeA2usingA2muscleA2relaxationA2techniques
D)A2ThinkA2aboutA2reasonsA2theA2episodesA2occurA2-A2Ans--
C)A2PracticeA2usingA2muscleA2relaxationA2techniques
TheA2chargeA2nurseA2isA2planningA2forA2theA2shiftA2andA2hasA2aA2RNA2andA2aA2PNA2onA2the
A2team.A2WhichA2clientA2shouldA2theA2chargeA2nurseA2assignA2toA2theA2RN?
A)A2AA275-yearA2oldA2clientA2withA2renalA2calculiA2whoA2requiresA2urineA2straining
B)A2AA264-yearA2oldA2clientA2whoA2hadA2aA2totalA2hipA2replacementA2theA2preiousA2day
C)A2AA230-yearA2oldA2depressesA2clientA2whoA2admitsA2toA2suicideA2ideation
D)A2AnA2adolescentA2withA2multipleA2contusionsA2dueA2toA2aA2fallA2thatA2occurredA22A2days
A2agoA2-A2Ans--C)A2AA230-
yearA2oldA2depressesA2clientA2whoA2admitsA2toA2suicideA2ideation
NGN:A2(NursesA2Notes)A2
1800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2toA2aA2G
A22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2FollowingA2aA2s
pontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2minuteA
2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2andA2appea
rsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat.A2SheA2
isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296F,A2puls
eA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2mongoli
anA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2(ForA2eachA2a
ssessmentA2finding,A2clickA2toA2indicateA2whetherA2theA2findingsA2areA2associatedA2withA2
anA2infantA2ofA2aA2diabeticA2motherA2orA2normalA2presentation.)
SoftA2Fontanelles
BloodA2GlucoseA235
AxillaryA2temp.A296F
Acrocyanosis
BallardA2scoreA2maturityA2ratingA237A2-A2Ans--DiabeticA2Findings:
BGA235
AxillaryA2tempA296
BallardA2scoreA2maturityA2ratingA237
???????
NormalA2Presentation:
SoftA2Fontanelles
Acrocyanosis
(normalA2findingsA2includeA2acrocyanosis,A2softA2fontanelles,A2mongolianA2spots,A2andA2A
pgarA2scoresA27A2toA210)
NGN:A2(NursesA2Notes)A2
1800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2toA2aA2G
A22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2FollowingA2aA2s
pontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2minuteA
,2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2andA2appea
rsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat.A2SheA2
isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296F,A2puls
eA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2mongoli
anA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
TheA2nurseA2recognizesA2thatA2theA2infantA2ofA2aA2diabeticA2motherA2isA2atA2riskA2forA2____
_____A2,A2_____________A2,A2andA2_________________A2-A2Ans--
HyperbilirubinemiaA2,A2ResppiratoryA2DistressA2SyndromeA2,A2andA2Cardiomyopathy
NGN:A2Orders
Breast-
feedA2immediatelyA2onceA2stableA2thenA2onA2demand.A2IfA2unstable,A2mayA2feedA2breastm
ilkA2viaA2orogastricA2tube.A2IfA2twoA2feedingA2attemptsA2failedA2toA2increaseA2theA2glucoseA
2levelsA2orA2ifA2symptomsA2ofA2hypoglycemiaA2develop,A2applyA2dextroseA2gelA2insideA2the
A2babiesA2cheek.A2IfA2theA2aboveA2areA2ineffective,A2IVA2glucoseA2shouldA2beA2administere
dA2toA2maintainA2glucoseA2levelsA2aboveA245.A2BolusA2ofA22mL/
kgA2glucoseA210%A2IV,A2helloA2byA2aA2continuousA2glucoseA2perfusionA2ofA26A2toA28mg/
kg/min,A2maintainA2glycemicA2levelsA2overA240.
WhichA26A2ordersA2takeA2priority?
A)A2FeedA2Immediately
B)A2MonitorA2forA2respiratoryA2distress
C)A2ApplyA2dextroseA2gellA2insideA2theA2baby'sA2cheekA2
D)A2KeepA2inA2warmerA2withA2bilirubinA2lights
E)A2MonitorA2tempA2everyA230A2min
F)A2BolusA22A2mL/kgA2glucoseA210%A2IV
G)A2ContactA2RTA2forA2ABGA2andA2oxygenA2therapy
H)A2Echo
I)A2TransferA2toA2NICU
J)A2BloodA2glucoseA2levelA2-A2Ans--A)A2FeedA2Immedicately
B)A2MonitorA2forA2RespiratoryA2Distress
D)A2KeepA2inA2warmerA2withA2biliA2lights
E)A2MonitorA2tempA2q30min
G)A2ContactA2RTA2forA2ABGA2andA2O2A2therapy
J)A2BloodA2glucoseA2level
NGNA2LaboratoryA2ResultsA2(sameA2caseA2ofA2patientA2whoA2justA2gaveA2birth)
WhichA2actionsA2areA2appropriateA2forA2theA2nurseA2toA2takeA2atA2thisA2time?A2SATA
A)A2KeepA2infantA2inA2warmerA2withA2biliA2lightsA2toA2maintainA2tempA2ofA297.6F
B)A2MonitorA2Temp
C)A2ContinueA2toA2monitorA2glucoseA2level
D)A2TellA2theA2motherA2thatA2sheA2willA2needA2toA2discussA2thisA2withA2theA2neonatologist
E)A2ExplainA2toA2theA2motherA2thatA2theA2babysA2RRA2needsA2toA2beA2belowA260
, F)A2InformA2theA2motherA2thatA2theA2babyA2isA2stableA2enoughtA2toA2takeA2outA2ofA2theA2wa
rmer
G)A2ObserveA2forA2signsA2ofA2respiratoryA2distressA2andA2monitorA2O2A2withA2pulseA2oxA2-
A2Ans--A)A2KeepA2infantA2inA2warmerA2withA2biliA2lightsA2toA2maintainA2tempA2ofA297F
E)A2ExplainA2toA2theA2motherA2thatA2theA2babysA2RRA2needA2toA2beA2belowA260
F)A2InformA2theA2motherA2thatA2theA2babyA2isA2stableA2enoughA2toA2takeA2outA2ofA2theA2war
mer
G)A2ObserveA2forA2signsA2ofA2respiratoryA2distressA2andA2monitorA2oxygenationA2byA2puls
eA2ox
NGN:A21800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2t
oA2aA2GA22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2Followin
gA2aA2spontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2
minuteA2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2and
A2appearsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat
.A2SheA2isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296
F,A2pulseA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2
mongolianA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
(ClickA2toA2highlightA2notesA2thatA2demonstrateA2aA2positiveA2outcome)
DayA22,A20630:A2VitalsA2haveA2remainedA2stableA2throughoutA2theA2night.A2OxygenA298%A
2onA2nasalA2canal.A2MotherA2toA2breastfeedA2inA2theA2nurseryA2onA2demand.A2AbleA2toA2tol
erateA2breastmilk.A2GlucoseA2afterA2feedingA2wasA260,A2tempA297.8F,A2whenA2returnedA2t
oA2warmerA2andA2biliA2light.A2CXRA2andA2echoA2resultsA2wereA2-A2Ans--
GlucoseA2afterA2feedingA2wasA260
DirectA2biliA25
TempA297.8
OxygenA298%A2
AbleA2toA2tolerateA2breastmilk
??????????
AA2clientA2withA2pancreatitisA2complainsA2ofA2severeA2epigastricA2pain,A2soA2theA2nurseA2a
dministersA2aA2prescribedA2narcoticA2analgesic.A2TenA2minutesA2later,A2theA2clientA2insists
A2onA2sittingA2upA2andA2leaningA2forward.A2WhichA2interventionA2shouldA2theA2nurseA2impl
ement?
A)A2RainsA2HOBA2toA290A2degrees
B)A2PositionA2bedsideA2tableA2soA2theA2clientA2canA2leanA2acrossA2it
C)A2PlaceA2bedA2inA2aA2reverseA2trenA2posiiton
D)A2EncourageA2restA2untilA2theA2analgesicA2becomesA2effective.A2-A2Ans--
B)A2PositionA2bedsideA2tableA2soA2theA2clientA2canA2leanA2acrossA2it
TheA2nurseA2isA2caringA2forA2aA2clientA2whoA2arrivesA2toA2theA2EDA2withA2reportsA2ofA2expe
riencingA2dizzinessA2andA2difficultyA2walkingA2toA2theA2bathroom.A2TheA2nurseA2observesA
2R-
sidedA2weaknessA2andA2sluggishA2enunciationA2ofA2speech.A2TheA2nurseA2shouldA2immed
iatelyA2takeA2whichA2action?
(NIGHTINGALE COLLEGE, 2025–2026) –
VERIFIED QUESTIONS AND CORRECT
ANSWERS, GRADE A
NGN:A21800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2t
oA2aA2GA22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2Followin
gA2aA2spontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2
minuteA2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2and
A2appearsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat
.A2SheA2isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296
F,A2pulseA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2
mongolianA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
(TheA2dayA2shiftA2nurseA2reviewsA2theA2nursesA2notes,A2labs,A2andA2flowA2sheetA2fromA2th
eA2nightA2before.A2TheA2nurseA2plansA2onA2providingA2healthA2teachingA2forA2theA2clientA2a
ndA2herA2familyA2inA2preparationA2forA2discharge.)
ForA2eachA2teachingA2point,A2clickA2toA2indicateA2whetherA2itA2isA2indicatedA2orA2contraindi
cated.A2OnlyA2oneA2rightA2optionA2perA2row.
A)A2YouA2willA2needA2toA2seA2-A2Ans--A)
B)
C)
D)A2Indicated
E)
?????????
TheA2nurseA2isA2providingA2teachingA2toA2aA2clientA2withA2typeA22A2DMA2aboutA2importantA2
pointsA2forA2diseaseA2andA2symptomA2management.A2WhichA2statementA2byA2theA2clientA2
indicatesA2understanding?
A)A2UsingA2salt,A2herbs,A2andA2spicesA2willA2improveA2theA2flavorA2ofA2foods
B)A2GetA2anA2eyeA2examA2withA2anA2opthalmologistA2annually
C)A2ArrangeA2dietA2scheduleA2aroundA2threeA2regularA2mealsA2aA2day
D)A2InspectA2feetA2everyA2monthA2forA2ingrownA2nails,A2cuts,A2andA2calusesA2-A2Ans--
B)A2GetA2anA2eyeA2examA2withA2anA2opthalmologistA2annually
TheA2nurseA2isA2providingA2educationsA2toA2aA2clientA2whoA2experiencesA2recurrentA2level
sA2ofA2moderateA2anxietyA2toA2situationsA2andA2perceivedA2stress.A2InA2additionA2toA2infor
mationsA2aboutA2prescribedA2medicationsA2andA2administration,A2whichA2instructionA2sho
uldA2theA2nurseA2includeA2inA2theA2teaching?
A)A2CenterA2attentionA2onA2positiveA2upbeatA2music
B)A2FindA2outletsA2forA2moreA2socialA2interactionA2
,C)A2PracticeA2usingA2muscleA2relaxationA2techniques
D)A2ThinkA2aboutA2reasonsA2theA2episodesA2occurA2-A2Ans--
C)A2PracticeA2usingA2muscleA2relaxationA2techniques
TheA2chargeA2nurseA2isA2planningA2forA2theA2shiftA2andA2hasA2aA2RNA2andA2aA2PNA2onA2the
A2team.A2WhichA2clientA2shouldA2theA2chargeA2nurseA2assignA2toA2theA2RN?
A)A2AA275-yearA2oldA2clientA2withA2renalA2calculiA2whoA2requiresA2urineA2straining
B)A2AA264-yearA2oldA2clientA2whoA2hadA2aA2totalA2hipA2replacementA2theA2preiousA2day
C)A2AA230-yearA2oldA2depressesA2clientA2whoA2admitsA2toA2suicideA2ideation
D)A2AnA2adolescentA2withA2multipleA2contusionsA2dueA2toA2aA2fallA2thatA2occurredA22A2days
A2agoA2-A2Ans--C)A2AA230-
yearA2oldA2depressesA2clientA2whoA2admitsA2toA2suicideA2ideation
NGN:A2(NursesA2Notes)A2
1800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2toA2aA2G
A22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2FollowingA2aA2s
pontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2minuteA
2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2andA2appea
rsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat.A2SheA2
isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296F,A2puls
eA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2mongoli
anA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2(ForA2eachA2a
ssessmentA2finding,A2clickA2toA2indicateA2whetherA2theA2findingsA2areA2associatedA2withA2
anA2infantA2ofA2aA2diabeticA2motherA2orA2normalA2presentation.)
SoftA2Fontanelles
BloodA2GlucoseA235
AxillaryA2temp.A296F
Acrocyanosis
BallardA2scoreA2maturityA2ratingA237A2-A2Ans--DiabeticA2Findings:
BGA235
AxillaryA2tempA296
BallardA2scoreA2maturityA2ratingA237
???????
NormalA2Presentation:
SoftA2Fontanelles
Acrocyanosis
(normalA2findingsA2includeA2acrocyanosis,A2softA2fontanelles,A2mongolianA2spots,A2andA2A
pgarA2scoresA27A2toA210)
NGN:A2(NursesA2Notes)A2
1800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2toA2aA2G
A22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2FollowingA2aA2s
pontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2minuteA
,2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2andA2appea
rsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat.A2SheA2
isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296F,A2puls
eA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2mongoli
anA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
TheA2nurseA2recognizesA2thatA2theA2infantA2ofA2aA2diabeticA2motherA2isA2atA2riskA2forA2____
_____A2,A2_____________A2,A2andA2_________________A2-A2Ans--
HyperbilirubinemiaA2,A2ResppiratoryA2DistressA2SyndromeA2,A2andA2Cardiomyopathy
NGN:A2Orders
Breast-
feedA2immediatelyA2onceA2stableA2thenA2onA2demand.A2IfA2unstable,A2mayA2feedA2breastm
ilkA2viaA2orogastricA2tube.A2IfA2twoA2feedingA2attemptsA2failedA2toA2increaseA2theA2glucoseA
2levelsA2orA2ifA2symptomsA2ofA2hypoglycemiaA2develop,A2applyA2dextroseA2gelA2insideA2the
A2babiesA2cheek.A2IfA2theA2aboveA2areA2ineffective,A2IVA2glucoseA2shouldA2beA2administere
dA2toA2maintainA2glucoseA2levelsA2aboveA245.A2BolusA2ofA22mL/
kgA2glucoseA210%A2IV,A2helloA2byA2aA2continuousA2glucoseA2perfusionA2ofA26A2toA28mg/
kg/min,A2maintainA2glycemicA2levelsA2overA240.
WhichA26A2ordersA2takeA2priority?
A)A2FeedA2Immediately
B)A2MonitorA2forA2respiratoryA2distress
C)A2ApplyA2dextroseA2gellA2insideA2theA2baby'sA2cheekA2
D)A2KeepA2inA2warmerA2withA2bilirubinA2lights
E)A2MonitorA2tempA2everyA230A2min
F)A2BolusA22A2mL/kgA2glucoseA210%A2IV
G)A2ContactA2RTA2forA2ABGA2andA2oxygenA2therapy
H)A2Echo
I)A2TransferA2toA2NICU
J)A2BloodA2glucoseA2levelA2-A2Ans--A)A2FeedA2Immedicately
B)A2MonitorA2forA2RespiratoryA2Distress
D)A2KeepA2inA2warmerA2withA2biliA2lights
E)A2MonitorA2tempA2q30min
G)A2ContactA2RTA2forA2ABGA2andA2O2A2therapy
J)A2BloodA2glucoseA2level
NGNA2LaboratoryA2ResultsA2(sameA2caseA2ofA2patientA2whoA2justA2gaveA2birth)
WhichA2actionsA2areA2appropriateA2forA2theA2nurseA2toA2takeA2atA2thisA2time?A2SATA
A)A2KeepA2infantA2inA2warmerA2withA2biliA2lightsA2toA2maintainA2tempA2ofA297.6F
B)A2MonitorA2Temp
C)A2ContinueA2toA2monitorA2glucoseA2level
D)A2TellA2theA2motherA2thatA2sheA2willA2needA2toA2discussA2thisA2withA2theA2neonatologist
E)A2ExplainA2toA2theA2motherA2thatA2theA2babysA2RRA2needsA2toA2beA2belowA260
, F)A2InformA2theA2motherA2thatA2theA2babyA2isA2stableA2enoughtA2toA2takeA2outA2ofA2theA2wa
rmer
G)A2ObserveA2forA2signsA2ofA2respiratoryA2distressA2andA2monitorA2O2A2withA2pulseA2oxA2-
A2Ans--A)A2KeepA2infantA2inA2warmerA2withA2biliA2lightsA2toA2maintainA2tempA2ofA297F
E)A2ExplainA2toA2theA2motherA2thatA2theA2babysA2RRA2needA2toA2beA2belowA260
F)A2InformA2theA2motherA2thatA2theA2babyA2isA2stableA2enoughA2toA2takeA2outA2ofA2theA2war
mer
G)A2ObserveA2forA2signsA2ofA2respiratoryA2distressA2andA2monitorA2oxygenationA2byA2puls
eA2ox
NGN:A21800:A2TheA2clientA2isA2aA2femaleA2neonateA2bornA2atA237A2weeksA2ofA2gestationA2t
oA2aA2GA22A2PA21A2mother,A2whoA2wasA2diagnosedA2withA2gestationalA2diabetes.A2Followin
gA2aA2spontaneousA2vaginalA2birth,A2sheA2receivedA2ApgarA2scoresA2ofA2sevenA2atA2oneA2
minuteA2andA2eightA2atA2fiveA2minutes.A2TheA2clientA2weighsA24036.97gA2(8lbsA29oz)A2and
A2appearsA2pinkA2withA2acrocyanosisA2andA2aA2moderateA2amountA2ofA2subcutaneousA2fat
.A2SheA2isA2notedA2toA2beA2slightlyA2jitteryA2atA230minA2ofA2age.A2AxillaryA2temperatureA296
F,A2pulseA2140,A2RRA280.A2BloodA2glucoseA235,A2BillyA2RubinA2seven,A2fontanellesA2soft,A2
mongolianA2spotA2notedA2onA2lowerA2back,A2BallardA2maturityA2ratingA237A2weeks.A2
(ClickA2toA2highlightA2notesA2thatA2demonstrateA2aA2positiveA2outcome)
DayA22,A20630:A2VitalsA2haveA2remainedA2stableA2throughoutA2theA2night.A2OxygenA298%A
2onA2nasalA2canal.A2MotherA2toA2breastfeedA2inA2theA2nurseryA2onA2demand.A2AbleA2toA2tol
erateA2breastmilk.A2GlucoseA2afterA2feedingA2wasA260,A2tempA297.8F,A2whenA2returnedA2t
oA2warmerA2andA2biliA2light.A2CXRA2andA2echoA2resultsA2wereA2-A2Ans--
GlucoseA2afterA2feedingA2wasA260
DirectA2biliA25
TempA297.8
OxygenA298%A2
AbleA2toA2tolerateA2breastmilk
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AA2clientA2withA2pancreatitisA2complainsA2ofA2severeA2epigastricA2pain,A2soA2theA2nurseA2a
dministersA2aA2prescribedA2narcoticA2analgesic.A2TenA2minutesA2later,A2theA2clientA2insists
A2onA2sittingA2upA2andA2leaningA2forward.A2WhichA2interventionA2shouldA2theA2nurseA2impl
ement?
A)A2RainsA2HOBA2toA290A2degrees
B)A2PositionA2bedsideA2tableA2soA2theA2clientA2canA2leanA2acrossA2it
C)A2PlaceA2bedA2inA2aA2reverseA2trenA2posiiton
D)A2EncourageA2restA2untilA2theA2analgesicA2becomesA2effective.A2-A2Ans--
B)A2PositionA2bedsideA2tableA2soA2theA2clientA2canA2leanA2acrossA2it
TheA2nurseA2isA2caringA2forA2aA2clientA2whoA2arrivesA2toA2theA2EDA2withA2reportsA2ofA2expe
riencingA2dizzinessA2andA2difficultyA2walkingA2toA2theA2bathroom.A2TheA2nurseA2observesA
2R-
sidedA2weaknessA2andA2sluggishA2enunciationA2ofA2speech.A2TheA2nurseA2shouldA2immed
iatelyA2takeA2whichA2action?