A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Respiratory findings
- B. Temperature
- C. Oxygen Saturation
- D. Central nervous system findings
- E. Gastrointestinal findings
Correct Answer: A, D, E
Rationale: The correct answers are A (Respiratory findings), D (Central nervous system findings), and E (Gastrointestinal findings). These are crucial areas to monitor in a newborn to ensure their well-being. Respiratory findings are important as newborns are prone to respiratory distress. Central nervous system findings are vital for assessing neurological status. Gastrointestinal findings are necessary to monitor feeding tolerance and bowel movements. Temperature, oxygen saturation, and other choices are also important but may not be as critical in this case. It is essential to focus on the key areas that can indicate potential issues and require immediate attention.
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Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: [0, 0, 0]
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.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia.
- B. Increased feeding.
- C. Hyperthermia.
- D. Respiratory distress.
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
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.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.