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Apgar scoring is conducted at 1 minute and 5 minutes after birth. It is used to determine:
- A. Major body systems' responses at birth
- B. Future intelligence of the newborn
- C. Level of parent and newborn interaction
- D. Gestational age of the newborn
Correct Answer: A
Rationale: The Apgar score assesses a newborn's physical condition immediately after birth by evaluating heart rate, respiratory effort, muscle tone, reflex response, and color. Therefore, the correct answer is A. The other choices are incorrect because B) the Apgar score does not predict future intelligence, C) it does not measure parent and newborn interaction, and D) it is not used to determine gestational age.
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The nurse is planning an educational session with a group of school-age children. Which primary task from Erikson's theory of psychosocial development should be addressed?
- A. Establishing trust in others
- B. Developing a sense of autonomy
- C. Developing a sense of industry
- D. Establishing a sense of identity
Correct Answer: C
Rationale: In Erikson's theory of psychosocial development, school-age children typically focus on developing a sense of industry. This stage, occurring during middle childhood, involves the desire to feel competent and productive in their skills and abilities. Choices A, B, and D are incorrect because establishing trust in others (A) is related to the first stage of Erikson's theory (trust vs. mistrust) which occurs in infancy, developing a sense of autonomy (B) is linked to the second stage (autonomy vs. shame and doubt) which occurs in early childhood, and establishing a sense of identity (D) is associated with the fifth stage (identity vs. role confusion) which occurs in adolescence.
The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)
- A. Hyponatremia
- B. Hyperkalemia
- C. All are applicable
- D. Elevated blood urea nitrogen level
Correct Answer: C
Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.
The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurse's intervention include?
- A. Explain the disorder so they can explain it to others.
- B. Help parents understand that this is a minor problem.
- C. Suggest that parents avoid family and friends until the gender is assigned.
- D. Encourage parents not to worry while the tests are being done.
Correct Answer: A
Rationale: It is important for the nurse to provide the parents with accurate information so they can confidently explain the situation to others, helping to reduce stress and misinformation. Avoiding family and friends or minimizing the problem is not helpful.
Parents would suspect hearing loss if their child did not:
- A. Turn away from a sound
- B. Startle with sudden loud noises immediately after birth
- C. Talk at 4 months
- D. Babble at 2 months
Correct Answer: D
Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.
The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
- A. All are correct
- B. Anorexia
- C. Hypertension
- D. Purpura
Correct Answer: A
Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.