A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin
level. Which of the following actions should the nurse take? - CORRECT ANSWERD. Use a
photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is
receiving the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of
the following findings should the nurse expect? - CORRECT ANSWERDark red vaginal bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark red
vaginal bleeding.
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the
following actions should the nurse perform? - CORRECT ANSWERCorrect Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and metabolic
activity. This process increases glucose consumption and puts the newborn at risk of
hypoglycemia.
Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally,
there is a potential fire risk from the bassinet linens and the vent.
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The
client begins to show indications of magnesium sulfate toxicity. Which of the following
medications should the nurse prepare to administer? - CORRECT ANSWERCorrect Answer:
C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion immediately and prepare to
administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent
cardiac and respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate
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