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A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Sternal and subcostal retractions
- D. Decreased respirations
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
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The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?
- A. Maternal bradycardia
- B. Fetal hypoglycemia
- C. Maternal tachycardia
- D. Fetal macrosomia
Correct Answer: C
Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?
- A. Give oral iron medication every day.
- B. Have the child's blood pressure monitored every week.
- C. Know the signs and symptoms of iron overload.
- D. Keep exercise at a minimum to reduce stress.
Correct Answer: C
Rationale: Oral iron supplements are contraindicated in thalassemia. Although heart failure may be an end result of this disease, this action is unnecessary. Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. Children should be encouraged to pursue activities related to their exercise tolerance.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client upright for meals
- C. Feed the client quickly
- D. Use a straw for fluids
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.