The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:

Correct Answer: C

Rationale: The behaviors described, such as slightly mottled skin, limp and extended extremities, hiccups, and a rapid but regular heart rate, are typical of preterm newborn behavior. Preterm infants often exhibit these characteristics due to their immature neurological and physiological systems. The mottled skin may be due to the immature vascular system, while the limp and extended extremities are common in preterm newborns as they have less muscle tone compared to full-term infants. Hiccups are also common in newborns, including preterm infants, and are generally not a cause for concern. The rapid heart rate is typical in newborns, particularly in the immediate postnatal period. Therefore, in this scenario, these behaviors are most likely related to the preterm status of the newborn rather than indicating stress, seizures, or respiratory distress.

Correct Answer: D

Rationale: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when there is not enough insulin in the body. In the absence of sufficient insulin, the body is unable to use glucose for energy, leading to the breakdown of fats for fuel. This results in the excessive production of ketone bodies, specifically acetoacetate and beta-hydroxybutyrate. As the ketone bodies accumulate in the blood, they lower the blood pH, leading to acidosis. This is what causes the characteristic symptoms of DKA, such as fruity breath, deep rapid breathing, and abdominal pain. Therefore, the excessive accumulation of ketone bodies from fat metabolism is the primary cause of diabetic ketoacidosis.

Correct Answer: D

Rationale: Responding to name usually occurs earlier, around 6-9 months.

Correct Answer: B

Rationale: One of the major risk factors for ovarian cancer is nulliparity, which means never having been pregnant. This is because pregnancy and childbirth have a protective effect against ovarian cancer. Women who have never been pregnant are at a higher risk of developing ovarian cancer compared to women who have had children. Age is also a significant risk factor for ovarian cancer, with the risk increasing as women get older. Therefore, the 45-year old woman who has never been pregnant has the highest risk of ovarian cancer among the given clients.

Correct Answer: C

Rationale: Following safer sex practices is the most important point for the nurse to stress when working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Safer sex practices, such as using condoms consistently and correctly, can help reduce the risk of transmitting the virus to others or acquiring other sexually transmitted infections. While avoiding the use of recreational drugs and alcohol is beneficial for overall health, it is not as crucial as practicing safer sex. Refraining from telling anyone about the diagnosis is not recommended, as social support is important for individuals living with AIDS. Telling potential sex partners about the diagnosis is also essential, not only for ethical reasons but also to prevent the transmission of the virus.