The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

Correct Answer: D

Rationale: The heart rate of a normal newborn is typically 120 to 160 bpm. Therefore, a heart rate of 80 bpm would be least likely to be observed in a normal newborn. This finding may indicate bradycardia, which should be further evaluated and managed by the healthcare provider. Other options such as an uneven head shape, irregular respirations, (+) Moro reflex are common and expected in newborns.

Correct Answer: C

Rationale: The nurse's best reply would be option C, "Your body does not make insulin, so the insulin injections help to replace it." This response directly addresses Tara's question about why she needs insulin injections instead of pills. In type 1 diabetes mellitus, the body's immune system mistakenly attacks the beta cells in the pancreas that produce insulin. As a result, individuals with type 1 DM do not produce insulin, so they require insulin injections to replace the missing hormone. Unlike type 2 diabetes where oral medications can be used to manage the condition, individuals with type 1 diabetes rely on insulin injections to regulate their blood glucose levels.

Correct Answer: C

Rationale: Thalassemia major is a genetic disorder characterized by abnormal hemoglobin production. Individuals with thalassemia major require frequent blood transfusions to manage their anemia, leading to iron overload in the body. Over time, this excess iron can accumulate in various organs such as the liver, heart, and endocrine glands, causing damage and dysfunction. This condition is known as hemochromatosis. Long-term complications of hemochromatosis include liver cirrhosis, heart failure, diabetes, and endocrine disorders. Therefore, the long-term complications seen in thalassemia major are primarily associated with hemochromatosis rather than anemia, growth retardation, or splenomegaly.

Correct Answer: C

Rationale: Digoxin is a medication commonly used to treat heart failure. One of the cardinal manifestations of digoxin toxicity is extreme bradycardia, which is characterized by a slower than normal heart rate. This can be a serious and potentially life-threatening symptom of digoxin toxicity, as it indicates that the medication is affecting the heart's electrical conduction system. Other symptoms of digoxin toxicity can include nausea, vomiting, vision changes, and confusion, but extreme bradycardia is a prominent sign that Nurse Tony should be vigilant for in his patient Clay, who has been diagnosed with heart failure.

Correct Answer: C

Rationale: When assessing a child with croup who is drooling and agitated, the nurse should be aware that examining the throat using a tongue depressor can potentially precipitate a complete airway obstruction. Croup is characterized by upper airway inflammation, particularly around the larynx and trachea, leading to a barking cough, hoarseness, and respiratory distress. In a child with croup who is already showing signs of airway compromise such as drooling and agitation, any manipulation in the throat area can cause further swelling and lead to a complete obstruction of the airway. This can be a life-threatening emergency requiring immediate intervention to secure the airway and ensure adequate oxygenation. Therefore, utmost caution should be taken when performing any procedures that may exacerbate the child's respiratory distress in this situation.