During the assessment of a newborn born at 40 weeks gestation at 12 hours of age, the nurse identifies localized swelling of the head that does not cross the suture line. The skin assessment reveals a bluish discoloration of the hands and feet. The respiratory rate is 50 with occasional pauses in the breathing lasting 5 seconds. The neonate is maintaining a temperature of 97.9 to 98.4. The neonate has had one wet diaper and one stool. The nurse determines the neonate is at greatest risk for which condition?

Which diagnostic test offers the most critical information for the nurse when assessing a client for suspected heart failure?

A 52-year-old postmenopausal client is taking tamoxifen after breast cancer surgery. During a follow-up visit, she reports: Leg swelling and tenderness in the left calf Vaginal spotting for the past two days Occasional hot flashes Mild fatigue Which action should be the priority for the nurse?

A 30-week gestation preterm infant is admitted to the NICU with grunting, nasal flaring, and intercostal retractions. The infant is placed on CPAP, and the healthcare provider prescribes exogenous surfactant via endotracheal tube. Which nursing action is most important immediately before surfactant administration?

A nurse is assessing a 7-month-old infant who was born at 30 weeks’ gestation. When the nurse asks the parent about developmental progress, which parent statement indicates a correct understanding of adjusted age for preterm newborns?

A client with systemic lupus erythematosus (SLE) is receiving hydroxychloroquine (Plaquenil). Which clinical manifestation should the nurse monitor for as a possible side effect of this medication?

Which statement by the client demonstrates understanding of the nurse’s teaching regarding sublingual nitroglycerin?

A client with polycystic kidney disease (PKD) has a blood pressure of 168/92 mmHg. What is the nurse’s priority action?

A client with rheumatoid arthritis is receiving prednisone for an exacerbation. Which clinical sign or symptom should the nurse recognize as a potential medication side effect?

A newborn is assessed at 1 minute of life. The nurse notes the following findings: Heart rate: 110 beats/min Respirations: slow, irregular Muscle tone: some flexion of extremities Reflex irritability: slow response to stimulation Color: body pink, hands and feet blue What is your patient’s APGAR score? ________________