A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?

Correct Answer: D

Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.

Correct Answer: A

Rationale: In this scenario, the highest priority action for the nurse caring for a one-year-old child following surgical correction of hypospadias is to monitor urinary output (Option A). This is because hypospadias repair surgery can lead to complications such as urinary retention, infection, or obstruction, which can impact the child's recovery and overall health. Monitoring urinary output is crucial in assessing renal function, fluid status, and the effectiveness of the surgical intervention. Changes in urinary output can indicate dehydration, renal complications, or issues with the surgical site. Early detection of these problems through monitoring urinary output allows for prompt intervention and prevents potential complications. The other options are not the highest priority in this situation. Auscultating bowel sounds (Option B) is important for assessing gastrointestinal function but is not as critical as monitoring urinary output in this postoperative period. Observing the appearance of stool (Option C) and recording the percent of diet consumed (Option D) are also important aspects of care but are not as immediate and essential as monitoring urinary output in this specific context. In an educational context, understanding the rationale behind prioritizing nursing actions based on the patient's condition and the potential complications of a surgical procedure is crucial for providing safe and effective care. Developing critical thinking skills to prioritize care based on the patient's needs and the clinical situation is a fundamental aspect of nursing practice in any specialty, including maternity care.

Correct Answer: D

Rationale: In this scenario, option D is the best choice as it promotes family-centered care and empowers the family members to make decisions together. Allowing the family to decide among themselves who will stay with the child during the procedure respects their autonomy and fosters a sense of control in a potentially stressful situation. This approach also encourages communication within the family and ensures that their preferences and needs are taken into account. Option A is incorrect because limiting the number of family members who can stay with the child may cause distress and disrupt family dynamics. It is essential to involve and support the family as a whole during times of medical intervention to provide emotional comfort and reassurance. Option B is inappropriate as it separates the child from their family members during a vulnerable moment, which can heighten the child's anxiety and feelings of isolation. Family presence has been shown to have positive effects on patient outcomes and satisfaction. Option C is not ideal as it isolates the sibling from the rest of the family without considering their emotional needs or the potential benefits of having familiar support nearby during the procedure. In an educational context, teaching healthcare providers about the importance of family-centered care and involving families in decision-making processes can enhance patient outcomes and satisfaction. By respecting and including families in care decisions, healthcare providers can create a supportive environment that promotes trust, collaboration, and positive health outcomes.

Correct Answer: A

Rationale: In this scenario, the most helpful intervention for the mother experiencing difficulty breastfeeding her newborn son is option A: Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on. This approach is beneficial because it addresses the immediate needs of both the mother and the baby. By stopping the feeding session, the mother can calm the baby and reduce stress for both of them, creating a more conducive environment for successful breastfeeding. Comforting the infant helps establish a sense of security and trust, making it easier for the baby to latch on when the feeding resumes. Assisting the mother in helping the baby latch on provides practical support and guidance, which can improve the breastfeeding experience for both mother and baby. Options B, C, and D are not the most appropriate interventions in this situation. Using a nipple shield (option B) may not address the underlying issue causing the baby's difficulty latching on and could potentially lead to further challenges with breastfeeding. Trying a different breastfeeding position (option C) could be helpful in some cases, but in this particular scenario where the baby is showing signs of distress and inability to latch on, immediate intervention and support are necessary. Having another person help the mother with breastfeeding (option D) may not address the root cause of the issue and could potentially create unnecessary dependency on external assistance. Educationally, understanding the importance of addressing breastfeeding challenges promptly and providing holistic support to both the mother and the baby is crucial in promoting successful breastfeeding outcomes. By prioritizing the well-being of both the mother and the newborn, healthcare providers can help establish a positive breastfeeding experience that supports the overall health and bonding of the mother-infant dyad.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Assess bilirubin level. Neonatal jaundice is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to effectively process bilirubin. Assessing the bilirubin level is crucial to determine the severity of jaundice and guide appropriate interventions. Option B) Administer phototherapy is a common treatment for neonatal jaundice, but it should not be the first step without assessing the bilirubin level first. Option C) Encouraging feeding to help reduce bilirubin levels is not the immediate action needed in this case. While breastfeeding can help with the elimination of bilirubin, it is not the primary intervention when jaundice is already present. Option D) Performing a bilirubin test every hour is excessive and not necessary. Monitoring bilirubin levels is important, but the frequency of testing should be based on the healthcare provider's assessment. Educationally, understanding the pathophysiology of neonatal jaundice, the importance of timely assessment, and appropriate interventions is crucial for nurses caring for newborns. This case highlights the significance of prioritizing assessments and interventions based on the clinical situation to provide safe and effective care for neonates.