The nurse is performing a physical examination on a 2-day-old newborn and notes flattened areas on each side of the head. The mother expresses concern about the infant's appearance
Which response by the nurse is appropriate?
1. "The baby will likely need a neurologic evaluation."
2. "The baby will need plastic surgery."
3. "This is normal and will resolve in a few days."
4. "What shape is your husband's head?"
Correct Answer: 3
Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. The infant's head will take on a more normal round shape in several days. The infant will not require a neurologic evaluation because this is a normal finding. The shape of the infant's head is normal after birth and is unrelated to the shape of the father's head.
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The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy:
Physical Assessment Vital Signs Physician Orders Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best? a. Administer the prescribed pain medication. b. Consult the surgeon about a different antibiotic. c. Consult the surgeon about increased IV fluids. d. Have respiratory therapy reduce the respiratory rate.
The nurse working in mental health nursing honors what historical nurse for working to improve care of the mentally ill?
1. Clara Barton 2. Florence Nightingale 3. Dorothea Dix 4. Lillian D. Wald
The patient is in isolation and in a room without windows. Which nursing action is most appropriate to help reduce or prevent sensory deprivation?
a. At regular intervals, ask the patient who she is and where she is. b. Engage the patient in conversation every two hours. c. Be sure the patient has a plant in her room. d. Tell the patient what day and time it is and discuss the weather at frequent intervals.
A member in a psychotherapy group tells another member, "I'm tired of hearing you whine all the time
Why won't you just try to stick with the topic we are trying to discuss?" The nurse recognizes that the criticized member of the group best understands the goal of group work when he is heard stating: a. "You are always criticizing me. Don't talk to me like that.". b. "I understand that you have a hard time talking with people. I do too.". c. "You seem to always say nasty things that will hurt people's feelings. Maybe you should think before you speak.". d. "I've learned that speaking without thinking often results in hurt feelings. We all need to think before we speak.".