Nokea
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Auscultate the newborn's apical pulse for 60 seconds
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence
Correct Answer: C
Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.
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A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?
- A. Heat the feeding to 105°F (40.6°C).
- B. Elevate the head of the bed to 45 degrees.
- C. Flush the tube with 0.9% sodium chloride.
- D. Verify the pH of the gastric aspirate.
Correct Answer: D
Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.
A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?
- A. Increased WBC count.
- B. Decreased hemoglobin.
- C. Decreased platelet count.
- D. Positive rheumatoid factor.
Correct Answer: D
Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.
A healthcare professional is reviewing the laboratory findings of a client who has diabetes mellitus. Which of the following findings indicates a need to revise the client's plan of care?
- A. Serum sodium 144 mEq/L.
- B. HbA1c 10%.
- C. Random serum glucose 190 mg/dL.
- D. Creatinine 1.2 mg/dL.
Correct Answer: C
Rationale: Elevated random serum glucose levels of 190 mg/dL indicate hyperglycemia and poor blood sugar control, requiring a revised plan of care. HbA1c levels above 7% also indicate long-term poor control of blood sugar. Serum sodium of 144 mEq/L and creatinine of 1.2 mg/dL are within normal ranges and do not directly indicate a need for a plan of care revision.
A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?
- A. I can clean the cat's litter box during pregnancy.
- B. I can visit someone with the flu after receiving the vaccine.
- C. I should take antibiotics for viral infections.
- D. I should wash my hands after gardening.
Correct Answer: C
Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?
- A. Diabetes mellitus
- B. Shoulder presentation
- C. Postterm with oligohydramnios
- D. Chorioamnionitis
Correct Answer: B
Rationale: Shoulder presentation is a contraindication for oxytocin because it can increase the risk of complications during labor, such as shoulder dystocia. Diabetes mellitus (Choice A) is not a contraindication for the use of oxytocin. Postterm with oligohydramnios (Choice C) and chorioamnionitis (Choice D) may actually necessitate the use of oxytocin to induce or augment labor for the well-being of the mother and baby.