The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse expect?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A 17-year-old student arrives at the emergency department (ED) complaining of severe abdominal pain and cramping that has worsened since the morning.

Her mother suspects a urinary tract infection due to her daughter’s frequent and urgent urination, or possibly appendicitis.

What signs would indicate that a healthy psychosocial adaptation is taking place? Select all that apply.

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry.
Based on these findings, which action should the nurse implement?

The nurse is instructing the parent of a 10-year-old child newly diagnosed with type 1 diabetes mellitus (DM) on how to administer subcutaneous insulin injections.

The parent expresses a fear of needles and is unable to perform the procedure.

What intervention should the nurse implement?

A client’s maternal serum alpha-fetoprotein level is elevated at 17 weeks.
What condition should the nurse identify as the likely cause of this increase?

The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

A child who weighs 55 pounds receives a prescription for isoniazid 10 mg/kg/day by mouth (PO) once a day.

The bottle is labeled, “Isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? . .

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse.
Which behavior best evidences the client’s adjustment to the disorder as an adolescent?