A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is option A: Encourage the mother to breastfeed the newborn. This is the appropriate choice because breastfeeding is the most natural and effective way to increase the newborn's blood glucose level. Breast milk contains the necessary nutrients and sugars that can help regulate the baby's glucose levels. Option B, gavage feeding 60 mL of glucose water, is incorrect because it introduces an unnecessary intervention that may not align with the infant's actual needs. Providing glucose water may also disrupt the establishment of breastfeeding. Option C, administering 10 mL of D W via IV, is not the first-line intervention for a newborn with low blood glucose levels. Intravenous administration should be reserved for severe cases where oral intake is not feasible or effective. Option D, rechecking the glucose level in 2 hours, is not the most appropriate immediate action when dealing with a newborn with low blood glucose levels. Prompt intervention is crucial to prevent further complications associated with hypoglycemia in neonates. In an educational context, understanding the significance of promoting breastfeeding for newborns is crucial for healthcare professionals working in maternity care. Encouraging breastfeeding not only provides optimal nutrition but also helps establish bonding between the mother and the infant. It is essential for nurses to prioritize evidence-based practices that support the well-being of both the newborn and the mother in maternity care settings.

Correct Answer: C

Rationale: In this scenario, the nurse should prioritize option C, which is to massage the client's fundus. Massaging the fundus helps to stimulate uterine contractions, which can effectively control postpartum bleeding by promoting the expulsion of clots and initiating the process of uterine involution. This intervention is crucial in preventing postpartum hemorrhage, a potentially life-threatening complication. Option A, elevating the client's legs, is not the priority in this situation as it does not address the underlying cause of the excessive bleeding. While elevating the legs can improve venous return and circulation, it is not as directly beneficial as fundal massage in managing postpartum hemorrhage. Inserting an indwelling urinary catheter (option B) is not the priority action because the client's excessive bleeding takes precedence. Monitoring urinary output is essential but can be done after addressing the bleeding. Initiating an infusion of oxytocin (option D) is a valid intervention to help control postpartum bleeding, but it should come after fundal massage. Oxytocin can be administered after ensuring that the uterus is contracting effectively through fundal massage. In an educational context, it is crucial for nurses caring for postpartum clients to understand the significance of fundal massage in managing postpartum hemorrhage. This knowledge ensures they can provide timely and appropriate care to prevent complications and promote maternal well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) "You should expect the test to take about 30 minutes." This statement is important to prepare the client for the duration of the nonstress test, ensuring they know what to expect and can plan their time accordingly. Option A is incorrect because nonstress tests do not typically require medication through an IV. Option C is also incorrect as fasting is not necessary for a nonstress test, so the client should not be advised to avoid eating or drinking before the test. Option D is incorrect because although nonstress tests are important in assessing fetal well-being, they do not specifically determine the maturity of the baby's lungs. From an educational perspective, it is crucial for nurses to provide accurate and relevant information to pregnant clients to alleviate anxiety, promote understanding, and ensure optimal prenatal care. By explaining the purpose and duration of the nonstress test, the nurse can empower the client to actively participate in their maternity care and make informed decisions regarding their health and the health of their baby.

Correct Answer: C

Rationale: The correct answer is C) Avoid having sexual intercourse for 24 hours before the Pap test. This information is crucial because sexual intercourse, as well as using certain products like douches or vaginal medications, can interfere with the accuracy of the Pap test results by affecting the quality of the sample collected. Educating the client about this guideline will help ensure the test results are reliable and effective in detecting any abnormalities in cervical cells. Option A is incorrect because the current guidelines recommend Pap testing every 3-5 years for most women aged 21-65, so a yearly test is not necessary or recommended until 70 years of age. Option B is incorrect as Pap tests are primarily used to detect abnormal cervical cells, not related to ovarian health or the removal of ovaries. Option D is also incorrect as Pap tests are specifically designed to detect abnormal cervical cell changes, not viral infections. In an educational context, it's important for nurses to provide accurate and up-to-date information to clients regarding preventive healthcare measures like the Pap test. By explaining the correct guidelines for preparing for a Pap test, nurses empower clients to take an active role in their health and well-being. This knowledge also helps clients understand the importance of following specific instructions to ensure the effectiveness of screening tests.

Correct Answer: D

Rationale: The correct answer is D) Wash the penis once per day with soap and water. This instruction is important because it promotes basic hygiene for the uncircumcised penis without causing harm. Washing the penis with soap and water helps to prevent infections and maintain cleanliness. Option A is incorrect because retracting the foreskin forcefully can cause pain and injury to the delicate tissues. It is crucial to emphasize that the foreskin should never be forcibly retracted in infants. Option B is incorrect as using a cotton swab to clean under the foreskin can also cause injury and may leave behind fibers, increasing the risk of infection. Option C is incorrect because applying petroleum jelly to the foreskin can create a breeding ground for bacteria, leading to infections. It is not recommended for routine care. In an educational context, it is essential for nurses to provide evidence-based and safe instructions to parents regarding newborn care. Proper hygiene practices should be taught to ensure the well-being of the infant and prevent potential complications. Nurses play a key role in educating parents on best practices for newborn care, including how to care for an uncircumcised penis.