Nokea
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.
- A. Blood type
- B. Parents religious affiliation
- C. Blood pressure
- D. Level of consciousness
- E. Hearing acuity
- F. Heart rate
- G. Deep tendon reflexes
Correct Answer: C,D,F
Rationale: Blood pressure, level of consciousness, and heart rate assess pain intensity and guide safe pain management. Blood type, religion, hearing, and reflexes are not directly relevant.
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Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?
- A. Administer antipyretic medication on a continuous basis.
- B. Continue strict monitoring of daily wet diapers for 1 week.
- C. Have the antibiotic trough level drawn within 3 days.
- D. Monitor the infant for response to auditory stimuli.
Correct Answer: D
Rationale: Monitoring auditory responses detects hearing loss, a common meningitis complication, requiring follow-up screening.
A client who is in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
- A. Notify the operating room team.
- B. Administer a fluid bolus of 500 mL.
- C. Administer oxygen via face mask.
- D. Place the client in Trendelenburg.
Correct Answer: D
Rationale: Trendelenburg positioning relieves umbilical cord compression, preventing fetal hypoxia in this emergency.
A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?
- A. 1+ edema on her lower extremities.
- B. Fundal height of 30 cm.
- C. Weight gain of 2 pounds (0.91 kg).
- D. Fetal heart rate of 110 beats/minute.
Correct Answer: B
Rationale: Fundal height of 30 cm is below the expected range (32-36 cm) for 34 weeks gestation, suggesting possible intrauterine growth restriction (IUGR) or oligohydramnios, which requires further evaluation. Mild edema is common, weight gain is normal, and a fetal heart rate of 110 bpm is within the acceptable range.
The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
- A. Arched back.
- B. Coffee-ground emesis.
- C. Projectile vomiting.
- D. Frequent pauses.
Correct Answer: C
Rationale: Projectile vomiting is characteristic of pyloric stenosis, indicated by the olive-like mass, hunger, and dehydration.