The nurse is assessing a patient for signs of heart failure. Which finding is most consistent with this condition?

Correct Answer: A

Rationale: The correct answer is A: Edema in the lower extremities. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the body, causing edema. Increased respiratory rate (B) may occur but is not specific to heart failure. Decreased blood pressure (C) and bounding pulse (D) are not typically seen in heart failure but may be present in other conditions. Edema is a classic sign of heart failure due to fluid retention from decreased cardiac output.

Correct Answer: C

Rationale: 37.7 degrees Celsius (rectal), is correct because newborns normal rectal temperature ranges from 36.6°C-38°C (97.9°F-100.4°F), with 37.7°C being typical. Oral (Choice A) isnt used in newborns due to safety and inaccuracy. 37°C axillary, is too low; axillary readings are 0.5°C-1°C below rectal (e.g., 36.5°C-37.2°C). 36.8°C axillary, fits axillary norms but isnt the questions focus. Rectal is the gold standard for neonates, reflecting core temperature despite their immature thermoregulation. Pediatric guidelines support 37.7°C as a common rectal value, making C the precise answer based on clinical practice.

Correct Answer: C

Rationale: Postoperative patients require careful assessment before rectal temperature measurement due to potential risks. Platelet count is critical because low platelets (thrombocytopenia) increase bleeding risk from rectal trauma, a concern after any surgery, even oral. Pain assessment is important but not specific to rectal contraindications unless related to rectal discomfort, which isn't indicated here. Pulse rate monitoring doesn't directly impact rectal temperature safety unless cardiac issues (e.g., post-MI) are present, which isn't the case. A fecal occult blood test detects bleeding but isn't a pre-measurement necessity. Choice C is correct as it addresses a key contraindication—bleeding risk—ensuring patient safety. This reflects nursing judgment in evaluating hematologic status before invasive temperature methods, especially post-surgery.

Correct Answer: D

Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.

Correct Answer: B

Rationale: Portable BP devices require recalibration for accuracy, a key teaching point. Random cuff placement or arm movement skews readings. Stethoscopes aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.