Nokea
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.
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In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.
Which of the following are probable signs, strongly indicating pregnancy?
- A. The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive sign of pregnancy.
- B. These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes.
- C. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward.
- D. These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.
Correct Answer: C
Rationale: The correct answer is C because Hegar's sign and Chadwick's sign are considered probable signs of pregnancy. Hegar's sign indicates softening of the lower uterine segment, a physiological change that typically occurs in pregnancy. Chadwick's sign refers to the bluish or purplish color of the cervix due to increased blood supply and estrogen levels in pregnancy. These signs are more specific to pregnancy compared to presumptive signs like quickening, which can be caused by other conditions. Ballottement is a technique used to assess fetal movement and position, not a sign indicating pregnancy certainty. Therefore, choices A, B, and D are incorrect as they refer to presumptive signs or signs that could be caused by conditions other than pregnancy.
A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away. Initially, which emotion should the nurse expect the mother to display after the transfer?
- A. Denial
- B. Frustration
- C. Guilt
- D. Anger
Correct Answer: C
Rationale: The correct answer is C: Guilt. The mother may feel responsible for the premature birth and subsequent transfer, leading to feelings of guilt. This is a common emotional response in such situations. Denial (A), frustration (B), and anger (D) may also be present, but guilt is the most likely initial emotion due to the perceived connection between the mother and the baby's health.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.