During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?

Correct Answer: C

Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention. Incorrect choices: A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding. B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action. D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.

Correct Answer: B

Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers. Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning. Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning. Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.

Correct Answer: D

Rationale: Step 1: NSAID response is variable - Different individuals respond differently to NSAIDs like naproxen due to genetic and physiological differences. Step 2: Trying another NSAID may be more effective - If the current NSAID is not effective, switching to a different one with a different mechanism of action may provide better pain relief. Step 3: Individualized approach - Tailoring the treatment to the individual's response is key in managing osteoarthritis pain effectively. Summary: Choice D is correct as it acknowledges the variability in NSAID response and suggests trying another NSAID if the current one is ineffective. Choices A, B, and C are incorrect as they do not address the variable response to NSAIDs and do not provide a solution to address the lack of pain relief.

Correct Answer: C

Rationale: The correct answer is C: Bureau of Vital Statistics. The Bureau of Vital Statistics is responsible for maintaining records on births, deaths, and other vital events in a particular region. Therefore, it is the most likely state resource to provide information on infant death rates. Disease registry (A) typically focuses on specific diseases rather than overall mortality rates. Department of Health (B) may have some data but may not specifically focus on vital statistics. Census data (D) provides population demographics but does not specifically track infant death rates.

Correct Answer: B

Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.