The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant (Select all that apply)?

a. Temperature instability d. Bradycardia
b. Irritability e. Hypertension
c. Lethargy


ANS: A, B, C
The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.

Nursing

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The perinatal nurse in the birthing unit is aware that according to the Emergency Medical Treatment and Active Labor Act (EMTALA), pregnant women should receive care for problems such as which of the following? (Select all that apply.)

A. A history of recent trauma B. Contractions that occur 20 minutes apart C. Decreased fetal movement D. Rupture of the membranes E. Sexually transmitted infections

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Which of the following best describes why nurses are increasingly becoming case managers when social workers have historically been so successful in the role?

a. Because of the need for ongoing patient assessment. b. Because of a shortage of licensed social workers. c. Nurses seek such roles as being easier than direct clinical care. d. Social workers expect higher salaries than nurses in the same role.

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The nurse is planning goals for a male client with the diagnosis of personality disorder. What is the main goal of the client's therapy?

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The LPN/LVN is reviewing a patient's list of nursing diagnoses. Which diagnoses should the LPN/LVN identify as a priority for this patient?

a. Anxiety b. Constipation c. Deficient fluid volume d. Ineffective airway clearance

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