Peds
A 5-year-old drops from the 39th percentile to the 4th percentile on the growth chart. What is the nurse’s priority action?
What is perform a full body assessment to gather more information and report to the provider?
This is the recommended time frame to screen for gestational diabetes during pregnancy.
What is 24–28 weeks?
An neonate's APGAR score of 4 (at 1 min) indicates this immediate nursing priority.
What is begin (or continue) resuscitation?
A pregnant patient at 14 weeks with Type 1 diabetes has frequent high blood glucose readings. This is the nurse’s priority action.
What is assess and manage blood glucose levels immediately?
A newborn has blue hands and feet at 2 hours of life with normal vital signs. This is the best nursing response to the mother.
What is “this is a normal finding for the first 24–48 hours after delivery”?
These abnormal findings in a toddler would require further evaluation during a routine assessment.
What are developmental delays, heart murmurs, or structural issues?
Edema, fatigue, constipation, and weight gain in a 28-year-old patient may indicate this condition.
What is hypothyroidism?
A newborn diagnosed with PKU requires this priority intervention to prevent complications.
What is initiating a low-phenylalanine diet immediately?
A newborn born to a mother with gestational diabetes is jittery and feeding poorly at 2 hours of life. This is the priority nursing action.
What is check the newborn’s blood glucose level?
A pregnant client with Type 1 diabetes at 20 weeks reports morning hypoglycemia. This is the nurse’s priority action.
What is instruct the client to increase carbohydrate intake at bedtime?
A key developmental milestone at 36 months (3 years) is this behavior.
What is engaging in play with other children?
A patient at 10 weeks gestation asks how to manage morning sickness. This is a common nursing instruction.
What is “try eating crackers or dry toast before rising in the morning”?
A full term newborn 30 minutes after birth has acrocyanosis, nasal flaring, RR 64, HR 150, temp 97.5°F, and a strong cry. This finding should be reported to the provider.
What is nasal flaring?
A 3-hour glucose tolerance test at 25.5 weeks shows a blood glucose value under 140 mg/dL. This is the nurse’s priority action.
What is teach blood glucose monitoring at home?
A patient with Type 1 diabetes is receiving a nutrition consult for diet control. This is the nurse’s priority teaching point.
What is manage blood glucose and consume low-sugar foods?
An 8-year-old with a tibial fracture in a cast develops increasing pain, swelling, tightness, and numbness. Compartment syndrome is suspected. This is the nurse’s priority action.
What is perform a neurovascular assessment and notify the provider immediately?
During labor, a fetal heart rate tracing shows recurrent late decelerations. This is the nurse’s priority intervention.
What is initiate intrauterine resuscitation?
A newborn with abnormal cardiovascular function is most likely to show this finding.
What is cyanosis?
A 3-hour-old newborn has jitteriness, poor feeding, and a blood glucose of 35 mg/dL. This is the priority nursing action.
What is administer oral glucose gel and initiate feeding?
A 32-week pregnant patient presents with a blood pressure of 168/112, severe headache, and visual disturbances. This is the priority medication the nurse should anticipate and teach about.
What is magnesium sulfate?
A 6-year-old child is hospitalized with (nephrotic syndrome). This is the best way for the nurse to include the family in the child’s care.
What is have the parents help with activities of daily living (ADLs)?
A 24-week pregnant patient reports feeling increasingly “down” during a prenatal visit. This tool is used to screen, diagnose, and monitor the severity of depression.
What is Patient Health Questionnaire-9 (PHQ-9) or the Perinatal Mood and Anxiety Disorders (PMADs) screening tools?
Which blood pressure reading is abnormal for a newborn?
A. 93/42
B. 100/53
C. 125/65
D. 85/49
What is C. 125/65?
A pregnant client at 26 weeks has a 1-hour glucose tolerance test result of 152 mg/dL and is anxious about having gestational diabetes. This is the nurse’s best response.
What is “This test is a screening, and many clients go on to pass the 3-hour test.”?
A nurse is teaching parents about car seat safety for an infant. This is the most important teaching point to emphasize.
What is placing the car seat in the middle of the back seat with a snug 5-point harness at or below the shoulders and the chest clip at armpit (axilla) level?