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The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?
- A. Tell the mother to wash the face with soap and apply powder.
- B. Tell her that 30% of newborns have a rash that will go away by one month of life.
- C. Report the rash to the doctor immediately.
- D. Ask the mother if anyone else in the family has had a rash in the last six months.
Correct Answer: B
Rationale: Newborn rashes, such as erythema toxicum, are common and typically resolve spontaneously within weeks, requiring no immediate intervention.
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The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
A client who is Muslim is refusing to eat food served to him by a nursing assistant. The nurse should do which of the following? Select all that apply.
- A. arrange a mealtime that will avoid prayer times
- B. remove farm-raised catfish from the food tray
- C. arrange with the family for halal food to be brought from home
- D. deliver food by a nursing assistant of the same sex
Correct Answer: A, C
Rationale: Arranging mealtimes to avoid prayer times and providing halal food respects the client's religious dietary practices. The gender of the assistant and specific foods like catfish are less relevant unless explicitly non-halal.
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
- A. cardiac arrhythmia.
- B. increased blood pressure.
- C. irregular respirations.
- D. decreased heart rate.
Correct Answer: A
Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.
Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.
An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01 mg PO q 12 hrs. The bottle is labeled 0.10 mg per 1/2 tsp. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz. of water
Correct Answer: B
Rationale: The calibrated dropper ensures accurate dosing of Lanoxin (digoxin), critical for preventing toxicity in infants.