A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.

Correct Answer: A

Rationale: The correct statement the nurse should make to the client receiving misoprostol intravaginally is, "You will need to stay in a side-lying position for 30 minutes after each dose." This instruction is important because maintaining a side-lying position can help prevent leakage and promote proper absorption of the medication. It enhances the effectiveness of the medication and reduces the risk of its expulsion before absorption, ultimately leading to a better response to the treatment. The other options are not relevant to the administration of misoprostol intravaginally and do not align with best practice for this specific therapy.

Correct Answer: B

Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.

Correct Answer: B

Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.

Correct Answer: D

Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.