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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.
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Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
- A. A temperature of 98.6°F (37.2°C) that occurs during the evening
- B. The child cannot recall items eaten for lunch the previous day
- C. The child vomits after awakening from a nap and again 1 hour later
- D. The VP shunt is palpable along the posterolateral portion of the skull
Correct Answer: C
Rationale: Persistent vomiting (C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (A), memory lapses (B), and palpable shunt (D) are not concerning.
The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? Select all that apply.
- A. I have had four sexual partners during my lifetime.
- B. I have smoked cigarettes for many years.
- C. I never used birth control pills because my partners wore condoms.
- D. I received treatment for chlamydia when I was younger.
- E. I tested positive for human papillomavirus a few years ago.
Correct Answer: A,B,D,E
Rationale: Cervical cancer is strongly linked to HPV infection (E), which is transmitted through sexual activity, including with multiple partners (A). Smoking (B) increases risk by impairing immune response to HPV. Chlamydia (D) is associated with chronic inflammation, increasing susceptibility. Condom use (C) reduces but does not eliminate HPV risk and is not a direct risk factor.
A client is diagnosed as having secondary Cushing's syndrome. The nurse knows that the client has most likely been taking which medication?
- A. Estrogen
- B. Penicillin
- C. Lovastatin
- D. Prednisone
Correct Answer: D
Rationale: Secondary Cushing's syndrome is often caused by long-term prednisone use, a corticosteroid mimicking cortisol excess. Estrogen, penicillin, or lovastatin do not cause this condition.
The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
- A. The client demonstrates putting eye drops in the conjunctival sac.
- B. The client has a patch on the affected eye.
- C. The client bends over to pick up the cat.
- D. The client is wearing slip-on shoes.
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal just before retiring
- C. Take sodium bicarbonate and water after each meal
- D. Sleep with head propped on several pillows
Correct Answer: D
Rationale: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.