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A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms, including gastrointestinal issues like vomiting. This is due to the sudden absence of the drug after birth. Choices A, B, and C are unrelated to SSRI withdrawal. Large for gestational age is more indicative of maternal diabetes, hyperglycemia is not a typical SSRI withdrawal symptom, and bradypnea is not commonly associated with SSRI use.
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During an outpatient clinic visit, a 13-year-old client is diagnosed with infectious mononucleosis. The nurse should expect which of the following to be included in the client's plan of care?
- A. Take acetaminophen (Tylenol) with codeine as prescribed for pain.
- B. Encourage gargling with warm water to alleviate pain.
- C. Start a short course of ampicillin.
- D. Encourage social activity to prevent depression.
Correct Answer: B
Rationale: The correct answer is B: Encourage gargling with warm water to alleviate pain. Gargling with warm water can help soothe a sore throat, a common symptom of infectious mononucleosis. Acetaminophen with codeine (A) is not typically recommended for mononucleosis pain management in children due to the risk of respiratory depression. Starting a short course of ampicillin (C) is contraindicated in mononucleosis as it can cause a rash. Encouraging social activity (D) may not be appropriate as the client may need rest to recover.
A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI?
- A. I should look for more frequent urination and strong-smelling urine.
- B. My child would have tea-colored urine and puffiness around the eyes.
- C. I should observe for episodes of nausea and less frequent urination.
- D. My child would have pale-colored urine and abdominal tenderness and pain.
Correct Answer: A
Rationale: Frequent urination and strong-smelling urine are classic signs of a UTI.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because condoms should be removed immediately after intercourse to prevent leakage of semen. Leaving the condom on for 30 minutes increases the risk of pregnancy and STIs. Choice A is correct as condoms should be put on when the penis is erect. Choice C is correct as leaving a space at the tip allows room for semen collection. Choice D is incorrect as spermicidal gels or creams are not recommended due to potential irritation and increased risk of STIs.
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first?
- A. "The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration."'
- B. "Exercise requires additional insulin since glucose will be released from the cells during activity."'
- C. "Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations."'
- D. "The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose."'
Correct Answer: A
Rationale: The correct answer is A because in this scenario, the child's sudden relief from pain after a CT scan could indicate a possible rupture of the appendix. This is a critical situation that requires immediate attention to prevent complications such as peritonitis. Monitoring fluid balance is crucial to prevent dehydration, especially if surgery is needed. Choices B, C, and D are incorrect and not the priority as they focus on managing diabetes, which is not the primary concern in this case. Monitoring glucose levels, adjusting insulin, or modifying the diet are not immediate actions required for a child with suspected appendicitis.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D. Giving the newborn a tub bath in two days after circumcision could increase the risk of infection as the circumcision wound needs time to heal. A sponge bath is recommended until the wound is completely healed. Choice A is correct because yellow exudate is normal during the healing process. Choice B is correct as keeping the area clean is important. Choice C is correct as circumcision typically heals within a couple of weeks.