The nurse is planning care for four infants who were born on this shift. Which infant will require the most detailed assessment? The infant whose mother:
1. Has a history of obsessive-compulsive disorder (OCD).
2. Has Chlamydia.
3. Has delivered six other children by cesarean section.
4. Has a urinary tract infection (UTI).
2
Rationale:
1. Obsessive-compulsive disorder (OCD) is not a risk factor for the infant.
2. Infants born to mothers with Chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and thus require close observation of the respiratory status and eyes.
3. The presence of multiple siblings, regardless of how they were delivered, is not a risk factor for the infant.
4. An infant whose mother has an untreated urinary tract infection might have been exposed to pathogens, but it is not known whether the mother is on antibiotics.
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A patient's medication administration record orders the IM administration of chlorpromazine. When administering this drug, the nurse should
A) observe the patient while he or she self-administers the drug. B) administer the drug into the deltoid muscle with a 1 1/2-inch needle. C) have the patient massage the injection site for 1 to 2 minutes after the injection. D) have the patient lie down for 30 to 60 minutes after the injection.
While assessing a client with smooth, taut, shiny skin in the calves and thighs, the nurse makes a 1 inch deep depression in the calf that is slow to disappear. The nurse charts that the client has:
1. +3 pitting edema of the calves. 2. mild edema in the calves of the legs. 3. fluid volume deficit. 4. hyponatremia.
Which assessment finding in a 36-year-old patient is most indicative of a need for further evaluation?
a. Bilateral breast nodules that are tender with palpation b. A breast nodule that is 1 cm in size, nontender, and fixed c. A breast lump that increases in size before the menstrual period d. A breast lump that is small, mobile, with a rubbery consistency
The right side of the heart cannot pump blood normally. Signs and symptoms include:
a. No pulse, no respirations, and no blood pressure b. Swollen feet and ankles c. Dyspnea, cyanosis, and elevated tempera-ture d. Severe, sudden chest pain