Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high-pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:

Correct Answer: C

Rationale: The correct answer is C) Hypoglycemia. In newborns of mothers with diabetes, there is a risk of hypoglycemia due to the sudden cessation of the maternal glucose supply post-birth. The symptoms described – jitteriness, weak cry, high-pitched cry, and irregular respirations – are classic signs of hypoglycemia in neonates. Option A) Hypovolemia is unlikely in this scenario as there are no signs of volume depletion such as poor perfusion or tachycardia. Option B) Hypocalcemia typically presents with symptoms like seizures, not jitteriness and weak cry. Option D) Hyperglycemia would not cause these specific symptoms; instead, it might lead to lethargy or poor feeding. Educationally, it is crucial for nurses in maternal and newborn care to understand the unique risks faced by infants of diabetic mothers, such as hypoglycemia, and to be able to recognize and manage these conditions promptly to prevent potential complications like seizures or long-term neurological issues. Early detection and intervention are key in ensuring the well-being of these newborns.

Correct Answer: A

Rationale: In this scenario, the highest priority health outcome for the neonate born at 34 weeks' gestation with the given vital signs is option A) Oxygenation will remain adequate. Adequate oxygenation is crucial for a premature infant as they are at higher risk of respiratory distress syndrome due to immature lungs. Option B) Body temperature will remain stable is important but secondary to oxygenation as hypothermia can be managed more easily than respiratory distress in a newborn. Option C) Weight will increase by 30g per day is important for overall growth but is not the immediate priority when the infant is at risk of respiratory compromise. Option D) Heart rate will recover to an acceptable range is significant but is usually a result of addressing the primary concern of oxygenation first. Educationally, this question highlights the importance of understanding the priorities in caring for a neonate, especially a preterm infant, and the critical nature of maintaining adequate oxygenation for their well-being and survival. It emphasizes the need for nurses to prioritize interventions based on the most urgent needs of the patient to ensure positive health outcomes.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take regarding a 9-year-old girl diagnosed with gonorrhea is option D: Report the girl's medical findings to child protective services. This is the appropriate course of action because gonorrhea in a prepubescent child raises concerns about possible sexual abuse, which must be reported to the appropriate authorities to ensure the child's safety and well-being. Option A is incorrect because hospital admission may not be necessary if the child's safety can be ensured in a different setting. Option B is also incorrect as discussing the need to stop future sexual encounters with a 9-year-old is not developmentally appropriate or effective in this context. Option C is irrelevant to the immediate concern of suspected child abuse. From an educational perspective, this question highlights the importance of recognizing signs of potential abuse in pediatric patients and the legal and ethical responsibilities healthcare providers have in reporting such cases to protect vulnerable children. It underscores the critical role nurses play in advocating for the health and safety of their patients, especially in cases of suspected abuse or neglect.

Correct Answer: C

Rationale: In maternal and newborn nursing, it is crucial for the nurse to consider various factors before administering medications to postpartum clients. In the case of Depo-Provera, the correct answer is C) The medicine is contraindicated if the woman has lung or esophageal cancer. This is because medroxyprogesterone acetate can potentially worsen the condition or interfere with the treatment of these cancers. Option A is incorrect because Depo-Provera is not a capsule that needs to be taken daily at the same time. Option B is irrelevant as using sunscreen is not a specific consideration for administering Depo-Provera. Option D is incorrect because it is actually recommended for clients to use an alternate form of birth control for the first two months after starting Depo-Provera to ensure effectiveness, not as a contraindication. Educationally, understanding medication contraindications is critical in providing safe and effective care to postpartum clients. Nurses need to have a comprehensive knowledge of medications, their indications, contraindications, and potential interactions to make informed decisions and prevent harm to patients. This case emphasizes the importance of thorough assessment and consideration of individual client factors before administering medications.

Correct Answer: D

Rationale: In teaching about treatment for pubic lice, it is crucial to emphasize the correct practices to ensure effective management. The correct answer, option D, stating that the pubic hair should be combed after shampoo is removed, is essential because combing helps to remove any remaining lice and nits, aiding in the eradication of the infestation. This step is integral in preventing reinfestation and ensuring treatment success. Option A, stating that antibiotics should be taken for a full 10 days, is incorrect because pubic lice are not treated with antibiotics; they are typically managed with topical medications like lice-killing shampoos or lotions. Option B, suggesting that all clothing should be pretreated with bleach before wearing, is inaccurate and potentially harmful. Bleach is not recommended for treating pubic lice infestations on clothing. It can be damaging to the skin and clothing fibers. Option C, indicating that shampoo should be applied for at least 2 hours before rinsing, is also incorrect. While timing for specific treatments may vary, prolonged application of lice-killing shampoo beyond the recommended duration can lead to skin irritation without providing additional benefits. In the educational context, it is important to highlight evidence-based practices for treating pubic lice, emphasizing the correct steps such as using recommended medications, following application instructions, and combing to remove lice and nits. By understanding and applying these principles, healthcare professionals and patients can effectively manage and prevent the spread of pubic lice infestations.