A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Decrease in heart rate

Increase in vagal nerve tone

Decrease in respiratory rate

Increase in muscle tone

Answer and Explanation

The Correct Answer is D

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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Correct Answer is B

Explanation

A. Cleanse the urethral meatus. This step occurs after preparing the sterile field and donning sterile gloves.
B. Apply sterile gloves. This is correct. The first step in the standardized procedure is to apply sterile gloves to maintain aseptic technique throughout the catheter insertion process.
C. Attach the pre-filled syringe to the inflation bulb. This step is part of the preparation but comes after the sterile gloves are applied.
D. Saturate the cotton balls with antiseptic. This step occurs after donning sterile gloves.

A. Increase dietary intake of fats. B. Reduce intake of fluids. C. Increase fiber gradually each day. D. Reduce dietary intake of probiotics.

Correct Answer is C

Explanation

A. Increase dietary intake of fats. While fats can help lubricate the intestines, increasing fat intake is not a primary recommendation for managing constipation. Focusing on fiber and fluid intake is more effective.
B. Reduce intake of fluids. Reducing fluid intake can worsen constipation. Adequate hydration is essential to soften stool and promote regular bowel movements.
C. Increase fiber gradually each day. Increasing fiber intake gradually helps prevent constipation. Fiber adds bulk to the stool and helps it move more easily through the digestive tract. A gradual increase prevents gas and bloating that can occur with a sudden high intake of fiber.
D. Reduce dietary intake of probiotics. Probiotics can actually aid in maintaining a healthy digestive system and can help with bowel regularity. Reducing them is not recommended for managing constipation.

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A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following steps of the standardized procedure should the nurse plan to take first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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