The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first?
1. Notify the physician.
2. Elevate the newborn's head.
3. Document the findings in the chart.
4. Assess for hypothermia immediately.
3
Explanation: 3. Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm.
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Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection?
a. Strict and frequent handwashing by all people having contact with the patient b. Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration c. Administration of combinations of prophylactic antibiotics d. Creation of a "sterile" environment for the patient with the use of laminar airflow rooms
Under a claims-made insurance policy, for which claim is the nurse protected?
1. Claims that were filed before the insurance coverage became active 2. Claims that are filed for incidents during the active period of the policy 3. Claims filed within a 30-day grace period before or after policy times 4. Claims for all future events, whether the policy is active at that time or not
A patient has inability to clear thick secretions from her airway. Which nursing interventions are appropriate to address this problem?
1. Encourage bedrest to conserve energy. 2. Administer pain medications as needed. 3. Position the patient on the unaffected side. 4. Encourage the patient to provide as much self-care as possible. 5. Encourage slow, deep breaths.
The nurse is preparing a community presentation on family development. Which statement should the nurse include?
1. The youngest child determines the family's current stage. 2. A family does not experience overlapping of stages. 3. Family development ends when the youngest child leaves home. 4. The stages describe the family's progression over time.