Which of the following complications is the newborn at incre...

The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased

For each finding below, click to specify if the finding is consistent with the disease process of Guillain-BarrÃ© syndrome, ischemic brain stroke, or lumbar disk herniation.

A. Radiating back pain
B. Difficulty swallowing
C. Recent viral infection
D. Ascending muscle weakness

Correct Answer: A,B,C,D

Rationale: Radiating pain is typical of disk herniation, swallowing issues occur in GBS and stroke, viral history and ascending weakness are specific to GBS.

The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.

The nurse should prioritize interventions for Select... - to prevent ... Select...

A. Deep venous thrombosis
B. Peripheral artery disease
C. Chronic venous insufficiency
D. Tissue necrosis
E. Pulmonary emboli
F. Venous stasis ulcers

Correct Answer: B,D

Rationale: Peripheral artery disease interventions aim to prevent tissue necrosis due to poor perfusion.

Click to highlight below the findings indicating that the client is improving.

A. Abdominal dressing removed. Wound is clean, dry, and intact with no bleeding or foul-smelling drainage.
B. Fundus is firm, midline, and at the umbilicus. Urine output was $500 \mathrm{~mL}$ over the past 4 hours.
C. Client states that she is too tired and sore to ambulate in room with nursing assistance.
D. Client states that she cannot properly latch the newborn during breastfeeding.
E. Tolerating oral labetalol; systolic BP has been 110-130 mm Hg and diastolic BP has been 70-80 mm Hg over the past 12 hours.
F. Client reports no headaches and remains free of seizures.

Correct Answer: A,B,E,F

Rationale: Clean wound , normal fundus and urine output , stable blood pressure , and absence of headaches/seizures indicate improvement.

The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

Which of the following interventions should the nurse anticipate when caring for this newborn? Select all that apply.

A. Administer oral glucose water with each feeding
B. Allow skin-to-skin contact with the mother when possible
C. Check the newborn's blood glucose levels
D. Initiate newborn feeding within the first hour after birth
E. Monitor the newborn's respiratory rate frequently
F. Wrap the newborn in warm blankets to alleviate tremors

Correct Answer: B,C,D,E,F

Rationale: Skin-to-skin contact , glucose checks , early feeding , respiratory monitoring , and warming prevent hypoglycemia and respiratory issues.

The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.

The nurse recognizes the client has most likely developed .........anticipate assisting with.........

A. An abscess
B. Colon cancer
C. Clostridiodes difficile infection
D. Collecting a stool culture
E. Preparing the client for a colostomy
F. Obtaining a repeat CT scan of the abdomen

Correct Answer: A,F

Rationale: A palpable mass and fever suggest an abscess , requiring a CT scan for confirmation.

NCLEX PN Exam Practice Test with NGN Related

Correct Answer: A,C,E