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A preterm infant receiving oxygen therapy develops worsening respiratory status and signs of chronic lung disease. What is the most likely contributing factor?

A nurse assesses a newborn with a fluctuant scalp mass that does not cross sutures and appears 48 hours after birth. What is the priority nursing implication?

A newborn has a murmur on day 1 of life and oxygen saturation of 88%. What is the nurse’s priority concern?

A nurse is caring for a toddler who interprets language literally. Which statement is most appropriate?

A newborn delivered via vacuum extraction develops a diffuse, boggy scalp swelling that crosses suture lines and increases in size over several hours. The infant becomes tachycardic and pale. Which action is the nurse’s priority?

A client has hallucinations during a period of severe depression and later continues to show psychotic symptoms even when mood symptoms lessen. Which nursing understanding is most accurate?

A client with paranoid personality disorder says, “I know the staff are talking about me behind my back.” Which nurse response is best?

A client 2 weeks after delivery is confused, emotionally labile, says the baby is “marked by evil,” and reports hearing voices. Which nursing action is the priority?

The nurse is working with a client undergoing treatment for bulimia nervosa who has been asked to use a self-monitoring diary. Which explanation by the nurse best supports the therapeutic purpose of self-monitoring?

A client with major depression says, “I can’t make even simple decisions anymore.” Which nursing action is best?