The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:
a. Alarm as this is a drastic weight loss
b. Concern as this may be an indicator of inadequate nutrition
c. Reassurance as this is a normal weight loss
d. Alertness as such weight loss is not expected
C
Neonates generally lose 7% to 10% of their birth weight in the first 3 to 5 days. The weight loss is usually gained back in 10 days. The loss of one-half pound is within 10%.
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A 66-year-old man has been admitted to the postsurgical unit after his immediate recovery from a prostatectomy
The patient has asked the nurse when he will be able to get up out of bed, since this subject was not addressed in his preoperative teaching. How should the nurse best respond to the patient's question about mobility and activity? A) "It's best to stay in bed for the first 36 to 48 hours after your surgery to prevent some of the common complications of your surgery." B) "I can help you get up as soon as you feel strong enough, but make sure you don't sit in a chair for too long." C) "You can probably get up as soon as your urinary catheter is removed." D) "See if you can sit on the edge of your bed for an hour or so before you try walking."
The nurse understands that currently the most common indication for aspirin therapy is:
a. treatment of rheumatoid arthritis. c. prevention of heart attacks. b. treatment of sports injuries. d. stimulation of prostaglandin production.
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient
The nurse's priority action will be to a. give IV morphine sulfate 4 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best?
1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "You're probably not pregnant, but we can check it out if you like."