The nurse is performing a cardiovascular assessment and auscultates a grade 3/6 murmur at the left lower sternal border. What should the nurse do next?

Correct Answer: B

Rationale: The correct answer is B: Document the murmur and report it to the physician. A grade 3/6 murmur is moderate in intensity and may indicate a significant underlying heart condition. By documenting and reporting it to the physician promptly, the nurse ensures timely evaluation and appropriate management. Reassessing the murmur in 30 minutes (choice A) may delay necessary intervention. Performing a complete physical examination to rule out other cardiac abnormalities (choice C) is important but may not be immediately necessary for addressing the murmur. Initiating cardiac monitoring immediately (choice D) is not the priority in this scenario; informing the physician for further evaluation is more crucial.

Correct Answer: A

Rationale: The correct answer is A: Abdominal aortic aneurysm. The detection of a pulsatile mass in the midline of the abdomen is highly indicative of an abdominal aortic aneurysm. This is because the aorta runs in the midline of the abdomen, and an aneurysm in this area can present as a pulsatile mass. An abdominal aortic aneurysm is a serious condition that requires immediate medical attention. Choices B, C, and D are incorrect because cholecystitis, pancreatitis, and gastritis do not typically present with a pulsatile mass in the midline of the abdomen.

Correct Answer: A

Rationale: The correct answer is A: Heart failure. An S3 heart sound is often indicative of volume overload and impaired ventricular function, both of which are common in heart failure. The S3 sound occurs in early diastole when the ventricle is rapidly filling. In contrast, choices B, C, and D are not typically associated with S3 heart sounds. Mitral valve regurgitation causes a murmur, aortic stenosis causes a systolic murmur, and pulmonary embolism does not typically produce S3 heart sounds.

Correct Answer: C

Rationale: Neonate, is correct because the normal body temperature range for newborns (birth to 28 days) is approximately 96.0°F to 99.5°F, depending on measurement site (e.g., axillary). Neonates have immature thermoregulation, leading to a slightly wider and lower range than adults. Toddler (1-3 years), typically has a range closer to 97.5°F-100.4°F. Adolescent, aligns with adult norms (97°F-99°F). Middle adult, also falls within 97°F-99°F, narrower than the neonate range. Neonates susceptibility to environmental changes and less efficient hypothalamus function explain this broader range. Clinical practice confirms 96.0°F-99.5°F as typical for neonates, especially in controlled settings like nurseries, making C the accurate answer based on pediatric physiology.

Correct Answer: C

Rationale: Rectal temperature measurement is contraindicated in specific cases due to risks. For a newborn with hypothermia , its avoided due to fragile rectal tissue and potential perforation risk. A child with pneumonia has no specific rectal contraindication unless diarrhea is present, which isnt mentioned. An older adult post-myocardial infarction is at risk because thermometer insertion can stimulate the vagus nerve, slowing the heart rate, which is dangerous post-MI. A teenager with leukemia may have neutropenia, making rectal measurement risky due to infection potential from low white blood cell counts. Choice C is highlighted as correct in the context, supported by the vagus nerve risk. Other contraindications like rectal surgery or low platelets also apply but align with Cs cardiac focus here. This reflects nursing judgment in prioritizing patient safety based on physiological risks.