Nokea
A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
- A. A newborn who has a short frenulum and is having difficulty breastfeeding
- B. A newborn who is 24 hr old and has not had a meconium stool
- C. A newborn who is 10 hr old and has blood-tinged discharge in her diaper
- D. A newborn who is 10 hr old and has new onset tachypnea
Correct Answer: D
Rationale: New onset tachypnea signals potential respiratory distress, requiring urgent assessment, unlike breastfeeding issues, delayed stool, or normal blood-tinged discharge.
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A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?
- A. Dizziness
- B. Increased urination
- C. Double vision
- D. Sweating
Correct Answer: B
Rationale: Increased urination (polyuria) is a hallmark of hyperglycemia as the body excretes excess glucose, unlike dizziness, double vision, or sweating (more hypoglycemic symptoms).
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will return to the clinic in 8 weeks for my next injection
- B. I will get two shots each time I receive this medication
- C. I should increase my calcium intake while taking this medication
- D. I should discontinue this medication if I experience spotting
Correct Answer: C
Rationale: Increased calcium intake mitigates bone density loss from medroxyprogesterone, unlike incorrect 8-week injections (12 weeks), multiple shots, or stopping for spotting (normal).
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?
- A. Cool, Clammy skin
- B. Respiratory rate 18/min
- C. Bounding pulses
- D. Urinary output 30 mL/hr
Correct Answer: A
Rationale: Cool, clammy skin results from vasoconstriction in hypovolemic shock, unlike normal respiratory rate, bounding pulses (compensatory tachycardia typical), or low-normal urine output.
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
- A. Decrease in frequency of contractions
- B. BP 150/100 mm Hg
- C. Absent deep tendon reflexes
- D. Urinary output 35 mL/hr
Correct Answer: C
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, a serious complication requiring immediate reporting to prevent further harm, unlike reduced contractions (desired effect), elevated BP (monitor but less urgent), or low-normal urine output.
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.