The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low-set. Which of the following nursing actions would be most appropriate initially?
1. Notify the physician.
2. Document the findings.
3. Arrange for hearing testing.
4. Cover the ears with gauze pads.
1
Rationale: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appro-priate action would be to notify the physician. The options "arrange for hearing testing" and "cover the ears with gauze pads" are inaccurate and inappropriate nursing actions. "Document the findings" is not an initial action.
You might also like to view...
The nurse is assessing an older adult postmenopausal client. Which question should the nurse ask to assess for signs of osteoporosis?
A) "Have you experienced any palpitations?" B) "Are you having any low back pain?" C) "Are you having problems with swelling in your feet?" D) "Is constipation a problem for you?"
Which of the following actions occurs in a cell-mediated response?
A) Toxins of invading antigens are neutralized. B) The invading antigens link together (agglutination). C) The invading antigens precipitate. D) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
A child has ringworm of the scalp. A culture of the lesion reveals a dermatophytic infection. The nurse teaching the child's parents about how to treat this infection will include which statement?
a. "Adverse effects of the medication in-clude itching, burning, and erythema." b. "Apply the topical medication daily until at least 1 week after the rash is gone." c. "Your child will need to take this oral medication for 6 to 8 weeks." d. "You will use an antifungal shampoo to treat this infection."
A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a "bit of fatigue and shortness of breath."
Which of the following should the nurse explain to this patient? 1. fatigue is the first symptom of angina 2. shortness of breath is the first symptom of angina 3. the diabetes has caused you to have reduced pain sensitivity so the fatigue and shortness of breath were the symptoms that you felt 4. there is no classic symptom of angina