When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which interventions should the nurse implement? 

a. Review transcutaneous bilirubin levels with a bilirubinometer 

b. Observe and palpate newborn’s breast tissue for enlargement 

c. Assess for signs of fluid retention and bilateral pedal edema 

d. Explain to mother that the finding is due to increased androgen


An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for enteral feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care? 

a. Offer a pacifier for non-nutritive sucking 

b. Ensure placement of the gastronomy tube with an abdominal X-ray 

c. Use sterile technique during feedings 

d. Speak to the healthcare provider about instituting physical therapy


the nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea a paroxysmal nocturnal dyspnea. The nurse identifies crackles in all lung fields and use of accessory muscles. Which action should the nurse include in the client’s plan of care?

a)       Assess the client’s commitment to their daily exercise regimen

b)      Administer the prescribed amiodarone immediately

c)       Institute a daily fluid restriction while the client is in the hospital

d)      Arrange a prescribed electrophysiology study ( EPS) for the client


A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the scales of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect? 

a. Mononucleosis 

b. Syphilis 

c. Toxic shock syndrome. 

d. Herpes simplex virus


when the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus, the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

(a) Refer Client to the social worker for support therapy

(b) Encourage client to implement relaxation techniques

(c) leave the client’s room and return later in the day

(d) Explain that insulin is a life-saving drug for the client