Solutions
A nurse is assessing a client who has gestational diabetes mellitus and is
experiencing hyperglycemia. Which of the following findings should the nurse
expect?
A) Reports increased urinary output
B) Diaphoresis
C) Reports blurred vision
D) Shallow respirations - Answer-A) Reports increased urinary output
Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain,
constipation, drowsiness, and headaches are manifestations of hyperglycemia.
Other manifestations include weak rapid pulse, fruity breath odor, urine positive
for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is caring for a client who is at 22 weeks gestation and is HIV positive.
Which of the following actions should the nurse take?
A) Administer penicillin G 2.4 million units IM to the client.
B) Instruct the client to schedule an annual pelvic examination.
C) Tell the client she will start medication for HIV immediately after delivery.
D) Report the client's condition to the local health department. - Answer-D)
Report the client's condition to the local health department.
,A nurse is observing a new parent caring for her crying newborn who is bottle
feeding. Which of the following actions by the parent should the nurse recognize
as a positive parenting behavior?
A) Lays the newborn across her lap and gently sways
B) Places the newborn in the crib in a prone position
C) Offers the newborn a pacifier dipped in formula
D) Prepares a bottle of formula mixed with rice cereal - Answer-A) Lays the
newborn across her lap and gently sways
This is a correct technique for quieting a newborn. This tactile stimulation
promotes a sense of security for the newborn.
A nurse is teaching a newly licensed nurse about collecting a specimen for the
universal newborn screening . Which of the following statements should the
nurse include in the teaching?
Obtain an informed consent prior to obtaining the specimen."
"Collect at least 1 milliliter of urine for the test."
"Ensure that the newborn has been receiving feedings for 24 hours prior to
obtaining the specimen."
"Premature newborns may have false negative tests due to immature
development of liver enzymes." - Answer-"Ensure that the newborn has been
receiving feedings for 24 hours prior to obtaining the specimen."
The nurse should ensure that the newborn has been receiving regular feedings for
at least 24 hr prior to testing.
, The nurse is caring for a patient who has uterine atony and is experiencing
postpartal hemorrhage. Which of the following actions is the nurse's priority?
Check the client's capillary refill.
Massage the client's fundus.
Insert an indwelling urinary catheter for the client.
Prepare the client for a blood transfusion. - Answer-Massage the client's fundus.
Uterine atony and postpartum hemorrhage indicate that this client is at the
greatest risk for hypovolemic shock. This can compromise the perfusion to the
client's vital organs, which can lead to death. Therefore, the nurse's priority is to
massage the client's fundus to minimize blood loss.
A nurse is performing a PE of a newborn upon admission to the nursery. Which of
the following manifestations should the nurse expect. (Select all that apply)
Yellow sclera
Acrocynosis
Posterior fontanelle larger than anterior fontanelle
Positive Babinski reflex
Two umbilical arteries visible - Answer-Acrocynosis