Nokea
The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which of the following? Select all that apply.
- A. Fever.
- B. Vomiting.
- C. Diarrhea.
- D. Poor feeding.
- E. Abdominal pain.
Correct Answer: A,B,D
Rationale: Bacterial meningitis in infants commonly presents with fever, vomiting, and poor feeding. Diarrhea and abdominal pain are less typical symptoms in this age group.
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A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
The nurse instructs the client who is taking gentamicin to monitor factors related to renal function. The nurse determines that the client needs additional instruction when he makes which of the following statements?
- A. I should call you if I notice that I'm not urinating as much.'
- B. I should call you if my urine looks dark or unusual.'
- C. I should call you if my legs swell or I notice my skin looks puffy around my eyes.'
- D. I should call you if I have a fever.'
Correct Answer: D
Rationale: Gentamicin can cause nephrotoxicity, so monitoring for decreased urine output, dark urine, or edema (swelling) is appropriate. Fever is not directly related to renal function, indicating a need for further instruction.
A client with a diagnosis of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity?
- A. Tachycardia.
- B. Yellow vision.
- C. Weight gain.
- D. Dry cough.
Correct Answer: B
Rationale: Yellow vision is a classic sign of digoxin toxicity, indicating the need for immediate evaluation.
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
- A. An audible respiratory grunt
- B. Slight increase in the respiratory rate
- C. Arterial blood pH increases to ≥ 7.35
- D. Fine inspiratory crackles heard over both lungs
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
Which of the following should be the nurse's priority assessment after an epidural anesthetic has been administered to a client in labor?
- A. Level of consciousness.
- B. Blood pressure.
- C. Cognitive function.
- D. Contraction pattern.
Correct Answer: B
Rationale: Epidurals can cause hypotension due to vasodilation, making blood pressure the priority assessment.