following actions should the nurse take?
Administer opioids for pain
A nurse is assessing a 10-day-old client. Which of the following should the nurse understand is a
clinical manifestation of pyloric stenosis?
Projectile vomiting after feedings
Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the
duodenum, resulting in projectile vomiting.
A nurse is planning care for an adolescent who is postoperative following scoliosis repair with
Harrington rod instrumentation. Which of the following interventions should the nurse include in
the plan of care?
Initiate the use of a PCA pump for pain control
A nurse is assessing an adolescent who has attention deficit hyperactivity disorder (ADHD). Which
of the following findings should the nurse expect?
Impulsivity
A nurse is reviewing the laboratory results of a client who has acute leukemia and received an
aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory
values should the nurse expect? (Select all that apply.)
Decreased platelet count
Decreased leukocyte count
Decreased erythrocyte count
, A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunization to
15-month-old toddler. Which of the following findings is a contraindication for this immunization?
The child has a congenital immunodeficiency
A nurse is providing health promotion teaching to the parents of an infant. Which of the following
conditions should the nurse identify as the leading cause of death among this age group?
Congenital amnomalies
A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is
associated with increased pulmonary blood flow?
Patent ductus arteriosus
the area between the pulmonary artery and aorta remains open, allowing the blood to flow through
the patent ductus arteriosus and back to the pulmonary artery and lungs.
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A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to
the provider?
Inability to raise head when in prone position.
A 3 month-old infant should be able to raise her head and shoulders from prone position; therefore,
the nurse should report this finding to the provider.
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A school nurse is performing a routine health assessment for a school-age child. Which of the
following findings indicates the nurse should investigate further for pediculosis capitis?