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The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
- A. Newborns cannot hear well until they are at least 6 weeks old.
- B. Her concern is unfounded because hearing problems are rare in newborns.
- C. The majority of states now mandate that newborns undergo a screening test for hearing.
- D. The mother can test the baby's hearing by clapping her hands 24 inches from the infant's head.
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.
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A client with a history of heart failure is admitted with pulmonary edema. The nurse should administer which of the following medications as prescribed? Select all that apply.
- A. Furosemide (Lasix).
- B. Digoxin (Lanoxin).
- C. Nitroglycerin.
- D. Morphine.
- E. Aspirin.
Correct Answer: A, C, D
Rationale: Furosemide reduces fluid overload, nitroglycerin decreases preload, and morphine relieves anxiety and preload in pulmonary edema.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
- A. Heart rate
- B. Breath sounds
- C. Blood pressure
- D. Activity tolerance
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
- A. Impotence
- B. Mood swings
- C. Increased appetite
- D. Complete atrioventricular (AV) block
Correct Answer: A
Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.
The nurse is caring for a client with a history of Crohn's disease who is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild diarrhea.
- B. Abdominal pain.
- C. Fever.
- D. Headache.
Correct Answer: C
Rationale: Fever may indicate an exacerbation of Crohn's disease or a side effect of mesalamine, requiring immediate reporting.