Nokea
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a nonverbal sign of pain in newborns. It indicates stress and discomfort. Decreased heart rate, pinpoint pupils, and slowed respirations are not reliable indicators of pain in newborns and may be attributed to other factors. Therefore, the nurse should identify chin quivering as a significant sign of pain in this scenario.
You may also like to solve these questions
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours of unprotected sex. Taking it as soon as possible maximizes its effectiveness in preventing pregnancy by delaying or inhibiting ovulation. Choice B is incorrect as levonorgestrel can be used even if the person is on an oral contraceptive. Choice C is incorrect because a delayed period does not necessarily indicate pregnancy; a pregnancy test should be taken if there are other signs of pregnancy. Choice D is incorrect because levonorgestrel is only effective for a short period after taking it and does not provide long-term protection against pregnancy.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B because epigastric pain in a pregnant client at 34 weeks of gestation could indicate a serious condition such as preeclampsia. Preeclampsia is a potentially life-threatening condition characterized by high blood pressure and organ damage. It requires immediate assessment and intervention to prevent complications for both the mother and the baby. The other clients have less urgent issues that can be managed with ongoing monitoring and interventions. A: Gestational diabetes with a slightly elevated blood glucose level can be managed with adjustments to diet and medication. C: Mildly low hemoglobin levels can be addressed with iron supplementation and monitoring. D: Urinary frequency and dysuria in a client at 39 weeks of gestation are common symptoms of late-stage pregnancy and do not indicate a critical issue.
A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct answers to report to the provider are A, B, D, E, and F. A: Abdominal assessment is crucial to identify any potential underlying issues. B: Vaginal discharge in an adolescent may indicate infection or hormonal imbalance. D: Temperature abnormalities could signal infection. E: Dyspareunia (pain during intercourse) may indicate reproductive health concerns. F: Condom usage is important for safe sex practices. Choices C and G are not specifically related to the adolescent's care needs and do not require immediate reporting.
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 8 tablets
- B. 6 tablets
- C. 4 tablets
- D. 2 tablets
Correct Answer: C
Rationale: The correct answer is C: 4 tablets. Azithromycin 1g is equivalent to 1000mg. Since each tablet is 250mg, the nurse should administer 1000mg/250mg = 4 tablets. This dosage is appropriate for treating chlamydia infection. Choice A is incorrect because 8 tablets would be equivalent to 2000mg, which is double the prescribed dosage. Choice B is incorrect as 6 tablets would be 1500mg, which is higher than the prescribed dosage. Choice D is incorrect as 2 tablets would only be 500mg, which is lower than the prescribed dosage.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. Following an amniocentesis, leakage of fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice A) is a normal occurrence and not typically indicative of a complication. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common side effects post-amniocentesis and usually resolve without intervention.