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A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
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A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. Failure to pass meconium stool within the first 24-48 hours after birth can indicate a possible intestinal obstruction or other issues that need immediate attention. Reporting this finding to the provider is crucial for further evaluation and intervention.
Choices A, C, and D are normal findings in newborns and do not require immediate reporting. E, F, and G are not applicable in this context.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because in a nonstress test, the client is required to press a handheld button every time they feel their baby move. This action helps to monitor the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. This is essential at 37 weeks of gestation to ensure the baby is healthy and responding appropriately.
Summary of other choices:
A: Incorrect - The test duration can vary, but it typically takes longer than 10 to 15 minutes.
B: Incorrect - The client may need to change positions during the test to optimize fetal monitoring.
C: Incorrect - It is important for the client to eat and stay hydrated before the test to encourage fetal movement.
E, F, G: Choices not provided, thus irrelevant.
The nurse should first implement --- and ---
- A. Providing education on medications.
- B. Administering doxycycline.
- C. Administering ceftriaxone.
- D. Administering metronidazole and educating on condom.
- E. Administering metronidazole.
Correct Answer: B, C
Rationale: The correct answer is B, C. The nurse should first implement administering doxycycline and ceftriaxone in the treatment of certain infections like gonorrhea and chlamydia. Administering these antibiotics promptly is crucial to start the treatment process effectively. Providing education on medications (choice A) can follow once the initial treatment is administered. Administering metronidazole alone (choice E) or with educating on condoms (choice D) is not appropriate for the initial treatment of gonorrhea or chlamydia. Administering metronidazole alone would not effectively address these infections.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice C) can also dislodge the clot and should be avoided. Applying cold compresses (choice D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: To determine the correct answer, we look at the assessment findings. For "Greenish discharge," this is consistent with both trichomoniasis and gonorrhea. Trichomoniasis typically presents with a frothy, yellow-green discharge, while gonorrhea can cause a greenish or yellow discharge. "Pain on urination" is also a common symptom of both gonorrhea and trichomoniasis. Therefore, the correct answer is B, D. Abdominal pain is not specific to any of the mentioned conditions and is not a defining symptom. Diabetes is not directly related to the assessment findings provided. The absence of a condom is not a symptom but rather a risk factor for sexually transmitted infections.