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Questions 163

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Question 1 of 5

The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.

Question 2 of 5

The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.

Correct Answer: A,D,E

Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.

Question 3 of 5

The nurse is caring for a client with oral candidiasis who has a new prescription for nystatin oral suspension. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,D,E

Rationale: For nystatin oral suspension: avoid eating/drinking for 30 minutes to ensure contact time; monitor oral membranes for treatment response; shake the bottle for proper dosing; and swish in the mouth for efficacy. Discontinuing early risks recurrence.

Question 4 of 5

The nurse is screening clients for those at risk for developing oral candidiasis. The nurse should recognize the client at highest risk for developing oral candidiasis is a client who

Correct Answer: C

Rationale: An HIV-positive client on long-term antibiotics is at highest risk for oral candidiasis due to immunosuppression and microbial imbalance. Albuterol use , sugary drinks , and low albumin are less significant risk factors.

Question 5 of 5

A young adult has been diagnosed with Type 1 diabetes mellitus. The client asks how his condition differs from that of his grandmother who has Type 2 diabetes mellitus. What should the nurse include when replying?

Correct Answer: A

Rationale: Type 1 diabetes involves autoimmune destruction of pancreatic beta cells, causing insulin deficiency; Type 2 involves insulin resistance. Insulin may be used in Type 2, and diet or progression are not defining factors.

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