Nokea
The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Yellowing of the skin
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.
You may also like to solve these questions
The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism?
- A. Respiratory distress.
- B. Confusion.
- C. Petechiae.
- D. Fever.
Correct Answer: A
Rationale: Respiratory distress is the earliest symptom of fat embolism syndrome, as emboli obstruct pulmonary circulation, leading to hypoxia.
A client with a history of type 2 diabetes is prescribed sitagliptin (Januvia). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Monitor for signs of pancreatitis.
- C. Take the medication at bedtime.
- D. Stop the medication if blood glucose normalizes.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, requiring monitoring for abdominal pain.
Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home?
- A. I should eat a bland, soft diet.'
- B. It is important to eat six small meals a day.'
- C. I should drink several glasses of milk a day.'
- D. I should avoid alcohol and caffeine.'
Correct Answer: D
Rationale: Avoiding alcohol and caffeine is critical for peptic ulcer management, as these substances can exacerbate ulcer symptoms and delay healing.
A client with a history of breast cancer is prescribed tamoxifen (Nolvadex). Which side effect should the nurse teach the client to report?
- A. Hot flashes
- B. Weight gain
- C. Vaginal bleeding
- D. Fatigue
Correct Answer: C
Rationale: Vaginal bleeding may indicate endometrial hyperplasia or cancer, a serious side effect of tamoxifen requiring immediate reporting.
A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply.
- A. Hypotension.
- B. Bradycardia.
- C. Seizures.
- D. Profound pyrexia.
- E. Hypertension.
Correct Answer: C, D, E
Rationale: Sympathomimetic overdose can cause seizures, profound pyrexia (fever), and hypertension due to excessive stimulation of the sympathetic nervous system.