A nurse is planning care for a newborn who is receiving phototherapy for an elevatedbilirubin

level. Which of the following actions should the nurse take? - D. Use a photometer to monitor the

lamp's energy

The nurse should monitor the lamp's energy throughout the therapy to ensure thenewborn 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? - Dark red vaginal bleeding

The nurse should expect this client with a mild placental abruption to have minimal darkred

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 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 atrisk of

hypoglycemia.

Incorrect Answers:

A. The nurse should not obtain a rectal temperature from a newborn due to the risk ofrectal

perforation. Instead, the nurse should obtain an axillary temperature.

C. Bathing a newborn will increase heat loss. The infant should not be bathed until thetemperature

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 Answer:

C. Calcium gluconate

The nurse should discontinue the magnesium sulfate infusion immediately and prepareto

administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent

cardiac and respiratory arrest.