a nurse is returning phone calls in a pediatric clinic which of the following reports most requires the nurses immediate attention and phone call a nurse is returning phone calls in a pediatric clinic which of the following reports most requires the nurses immediate attention and phone call
Logo

Nursing Elites

NCLEX NCLEX-PN

Quizlet NCLEX PN 2023

1. A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse’s immediate attention and phone call?

Correct answer: An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.

Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.

2. A nurse monitoring a newborn infant notes that the infant’s respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?

Correct answer: Documenting the findings

Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.

3. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

Correct answer: She pulls a toy behind her

Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.

4. A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?

Correct answer: At the level of the nipples

Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.

5. A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which topic does the nurse ask the client about first?

Correct answer: Her menstrual history

Rationale: The nurse should begin by asking the client about her menstrual history as it is usually nonthreatening. This information can provide insights into the client's reproductive health and any irregularities. Menstrual history is a common starting point for gynecological assessments and can help in understanding the client's overall health status. Asking about sexual history may be more sensitive and personal, not always appropriate to start with. Obstetrical history pertains to pregnancies and may not be relevant if the client has not been pregnant. Inquiring about the presence of vaginal drainage is important but is usually addressed after gathering more general information about the client's health.

Similar Questions

What is appropriate care for a client with neutropenia?
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse’s best action at this time?
The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?
A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99