BSN 366 EXIT HESI STUDY NOTES
NIGHTINGALE COLLEGE FINAL PAPER
2026 NURSING INTERVENTIONS WITH
VERIFIED ANSWERS GRADED A+
⩥ The nurse is providing educations to a client who experiences
recurrent levels of moderate anxiety to situations and perceived stress. In
addition to informations about prescribed medications and
administration, which instruction should the nurse include in the
teaching?
A) Center attention on positive upbeat music
B) Find outlets for more social interaction
C) Practice using muscle relaxation techniques
D) Think about reasons the episodes occur.
Answer: C) Practice using muscle relaxation techniques
⩥ The charge nurse is planning for the shift and has a RN and a PN on
the team. Which client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the preious day
C) A 30-year old depresses client who admits to suicide ideation
,D) An adolescent with multiple contusions due to a fall that occurred 2
days ago.
Answer: C) A 30-year old depresses client who admits to suicide
ideation
⩥ NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G
2 P 1 mother, who was diagnosed with gestational diabetes. Following a
spontaneous vaginal birth, she received Apgar scores of seven at one
minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz)
and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30min of age.
Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy
Rubin seven, fontanelles soft, mongolian spot noted on lower back,
Ballard maturity rating 37 weeks. (For each assessment finding, click to
indicate whether the findings are associated with an infant of a diabetic
mother or normal presentation.)
Soft Fontanelles
Blood Glucose 35
Axillary temp. 96F
Acrocyanosis
Ballard score maturity rating 37.
Answer: Diabetic Findings:
BG 35
,Axillary temp 96
Ballard score maturity rating 37
???????
Normal Presentation:
Soft Fontanelles
Acrocyanosis
(normal findings include acrocyanosis, soft fontanelles, mongolian
spots, and Apgar scores 7 to 10)
⩥ NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G
2 P 1 mother, who was diagnosed with gestational diabetes. Following a
spontaneous vaginal birth, she received Apgar scores of seven at one
minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz)
and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30min of age.
Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy
Rubin seven, fontanelles soft, mongolian spot noted on lower back,
Ballard maturity rating 37 weeks.
The nurse recognizes that the infant of a diabetic mother is at risk for
_________ , _____________ , and _________________.
Answer: Hyperbilirubinemia , Resppiratory Distress Syndrome , and
Cardiomyopathy
, ⩥ NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may
feed breastmilk via orogastric tube. If two feeding attempts failed to
increase the glucose levels or if symptoms of hypoglycemia develop,
apply dextrose gel inside the babies cheek. If the above are ineffective,
IV glucose should be administered to maintain glucose levels above 45.
Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose
perfusion of 6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level.
Answer: A) Feed Immedicately
B) Monitor for Respiratory Distress
D) Keep in warmer with bili lights
NIGHTINGALE COLLEGE FINAL PAPER
2026 NURSING INTERVENTIONS WITH
VERIFIED ANSWERS GRADED A+
⩥ The nurse is providing educations to a client who experiences
recurrent levels of moderate anxiety to situations and perceived stress. In
addition to informations about prescribed medications and
administration, which instruction should the nurse include in the
teaching?
A) Center attention on positive upbeat music
B) Find outlets for more social interaction
C) Practice using muscle relaxation techniques
D) Think about reasons the episodes occur.
Answer: C) Practice using muscle relaxation techniques
⩥ The charge nurse is planning for the shift and has a RN and a PN on
the team. Which client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the preious day
C) A 30-year old depresses client who admits to suicide ideation
,D) An adolescent with multiple contusions due to a fall that occurred 2
days ago.
Answer: C) A 30-year old depresses client who admits to suicide
ideation
⩥ NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G
2 P 1 mother, who was diagnosed with gestational diabetes. Following a
spontaneous vaginal birth, she received Apgar scores of seven at one
minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz)
and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30min of age.
Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy
Rubin seven, fontanelles soft, mongolian spot noted on lower back,
Ballard maturity rating 37 weeks. (For each assessment finding, click to
indicate whether the findings are associated with an infant of a diabetic
mother or normal presentation.)
Soft Fontanelles
Blood Glucose 35
Axillary temp. 96F
Acrocyanosis
Ballard score maturity rating 37.
Answer: Diabetic Findings:
BG 35
,Axillary temp 96
Ballard score maturity rating 37
???????
Normal Presentation:
Soft Fontanelles
Acrocyanosis
(normal findings include acrocyanosis, soft fontanelles, mongolian
spots, and Apgar scores 7 to 10)
⩥ NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G
2 P 1 mother, who was diagnosed with gestational diabetes. Following a
spontaneous vaginal birth, she received Apgar scores of seven at one
minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz)
and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30min of age.
Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy
Rubin seven, fontanelles soft, mongolian spot noted on lower back,
Ballard maturity rating 37 weeks.
The nurse recognizes that the infant of a diabetic mother is at risk for
_________ , _____________ , and _________________.
Answer: Hyperbilirubinemia , Resppiratory Distress Syndrome , and
Cardiomyopathy
, ⩥ NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may
feed breastmilk via orogastric tube. If two feeding attempts failed to
increase the glucose levels or if symptoms of hypoglycemia develop,
apply dextrose gel inside the babies cheek. If the above are ineffective,
IV glucose should be administered to maintain glucose levels above 45.
Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose
perfusion of 6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level.
Answer: A) Feed Immedicately
B) Monitor for Respiratory Distress
D) Keep in warmer with bili lights
