Nokea
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
- A. Cyanosis of hands and feet
- B. Heart rate of 165/min while crying
- C. Jitteriness
- D. Respirations of 60/min
Correct Answer: C
Rationale: Jitteriness (C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (A) is normal, heart rate 165/min while crying (B) is within range, and respirations of 60/min (D) are normal for a newborn.
You may also like to solve these questions
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.
Which of these clients would be appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with multiple lacerations and requires complex dressings
- B. An elderly client with cystitis and an indwelling urethral catheter
- C. A confused client whose family complains about the nursing care 2 days after surgery
- D. A client admitted for possible transient ischemic attack with unstable neurological signs
Correct Answer: B
Rationale: This is a stable client, with predictable outcome and care and minimal risk for complications.
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
- A. Ataxia and coarse hand tremors
- B. Vomiting, diarrhea and lethargy
- C. Pruritus, rash and photosensitivity
- D. Electrolyte imbalance and cardiac arrhythmias
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.
A mother noticed a large abdominal mass when helping her 3-year-old child bathe. The child is taken to the physician and admitted to the hospital after an intravenous pyelogram (IVP) confirms the diagnosis of Wilms' tumor. Which nursing action is essential to include in the nursing care plan?
- A. Strain all urine and save for analysis.
- B. Avoid palpating the abdomen.
- C. Prepare the child for permanent dialysis.
- D. Help the family understand the poor prognosis.
Correct Answer: B
Rationale: Avoiding abdominal palpation prevents potential tumor rupture or metastasis in Wilms' tumor, a critical precaution. Urine straining, dialysis, or poor prognosis are inappropriate.