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The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following?
- A. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
- B. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
- C. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
- D. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
Correct Answer: C
Rationale: The correct answer is C. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. A is incorrect because full sole creases, nails extending beyond the fingertips, and scarf sign showing the elbow beyond the midline are features of a term infant. B is incorrect as testes located in the upper scrotum, rugae covering the scrotum, and vernix covering the entire body are also indicative of a term infant. D is incorrect because a 1 cm breast bud, peeling skin and veins not visible, and rapid recoil of legs and arms to extension are characteristics seen in a more mature infant, not a preterm newborn.
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A mother reported to you that her 6-year-old child is suffering from diarrhea. Which of the following advice will you give to the mother?
- A. Breastfeeding should be continued day and night
- B. Formula milk should be stopped for 6 hours
- C. Breast milk can be given together with oral rehydration salts
- D. A and C
Correct Answer: D
Rationale: When a child is suffering from diarrhea, it is essential to continue breastfeeding day and night to maintain hydration and provide necessary nutrients. Stopping formula milk for 6 hours (choice B) is not the recommended approach as it may lead to a lack of essential nutrients during this critical time. Giving breast milk together with oral rehydration salts (choice C) can help replenish lost fluids and electrolytes, making it a suitable recommendation. Therefore, advising the mother to follow both options A and C is the most appropriate approach to manage the child's condition effectively.
Are most children with hypertension asymptomatic?
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: The statement is true. In many cases, children with hypertension do not show any symptoms, making it challenging to diagnose them. Regular blood pressure checks are crucial to detect hypertension early, as it can have serious health implications if left untreated. Choice B is incorrect because most children with hypertension do not exhibit symptoms, hence being asymptomatic. Choices C and D are empty as they do not provide additional options.
Warning signs that indicate dehydration include all EXCEPT:
- A. Poor skin turgor
- B. Increased urine output
- C. Tachycardia
- D. Eager to drink
Correct Answer: B
Rationale: The correct answer is B. Increased urine output is not a warning sign of dehydration; it typically decreases with dehydration. Dehydration often presents with poor skin turgor, tachycardia, and an increased sensation of thirst (eager to drink) as the body tries to compensate for fluid loss. Choices A, C, and D are all correct warning signs of dehydration. Poor skin turgor is a result of decreased skin elasticity due to fluid loss. Tachycardia, an elevated heart rate, can be a compensatory mechanism to maintain cardiac output in dehydration. Feeling eager to drink is a common symptom of dehydration as the body attempts to restore fluid balance.
A postpartum client is concerned about hair loss. The nurse explains that this is:
- A. A sign of nutritional deficiency
- B. A temporary condition due to hormonal changes
- C. An indication of a thyroid disorder
- D. A result of poor hair care during pregnancy
Correct Answer: B
Rationale: Hair loss postpartum is a common temporary condition caused by hormonal changes that occur after giving birth. This condition is known as postpartum alopecia and is a normal part of the postpartum period. It is important for the nurse to reassure the client that this hair loss is temporary and usually resolves on its own without the need for medical intervention. Choice A is incorrect because postpartum hair loss is primarily due to hormonal changes rather than nutritional deficiency. Choice C is incorrect as thyroid disorder is not typically the cause of postpartum hair loss. Choice D is incorrect as poor hair care during pregnancy does not cause postpartum hair loss.
What assessment finding places a newborn at risk for developing physiologic jaundice?
- A. Cephalohematoma
- B. Mongolian spots
- C. Telangiectatic nevi
- D. Molding
Correct Answer: A
Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.