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A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a nonverbal sign of pain in newborns. It indicates stress and discomfort. Decreased heart rate, pinpoint pupils, and slowed respirations are not reliable indicators of pain in newborns and may be attributed to other factors. Therefore, the nurse should identify chin quivering as a significant sign of pain in this scenario.
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A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying can help soothe the baby by providing comfort and closeness. This position mimics the feeling of being held in the womb and the swaying motion can be calming. Placing the newborn in the crib in a prone position (B) is not recommended due to the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may lead to overfeeding and potential nipple confusion. Preparing a bottle of formula mixed with rice cereal (D) is not recommended for newborns as their digestive systems are not ready for solids.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: The correct answer is A: Apply warm compresses on the breasts before feedings. Warm compresses help to promote milk flow and relieve engorgement by increasing blood flow to the area. This can make it easier for the baby to latch and feed effectively. It is important to address engorgement promptly to prevent complications such as blocked ducts or mastitis.
Option B is incorrect because allowing the infant to nurse on one breast per feeding may not fully empty the breasts, leading to further engorgement. Option C is incorrect because aspirin is not recommended during breastfeeding due to potential risks to the infant. Option D is incorrect because wearing a tight-fitting underwire bra can constrict the breasts and worsen engorgement.
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 need to identify which assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis.
B: Greenish discharge is consistent with both trichomoniasis and gonorrhea due to their characteristic discharge color.
D: Pain on urination is a common symptom of gonorrhea, making it consistent with this condition.
Therefore, the correct answer is , as Greenish discharge and Pain on urination are consistent with gonorrhea. Abdominal pain and Diabetes are not specific to any of the mentioned conditions.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy, labor, and delivery. Oligohydramnios refers to a low level of amniotic fluid, which can indicate fetal distress or compromise. Monitoring the fetal heart rate patterns using electronic fetal monitoring in this case can help detect any abnormalities and guide appropriate interventions to optimize fetal outcomes.
Incorrect choices:
B: Hyperemesis gravidarum - This is severe nausea and vomiting in pregnancy, not a direct indication for fetal monitoring.
C: Leukorrhea - This is a common vaginal discharge in pregnancy, not a direct indication for fetal monitoring.
D: Periodic tingling of the fingers - This is not related to fetal assessment and is more likely a symptom of a different issue, such as nerve compression.