Nokea
A 42-week-gestation neonate is being assessed. Which of the following findings would the nurse expect to see?
- A. Folded and flat pinnae.
- B. Smooth plantar surfaces.
- C. Loose and peeling skin.
- D. Short pliable fingernails.
Correct Answer: C
Rationale: Post-term neonates often have loose and peeling skin due to prolonged exposure to amniotic fluid.
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A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
A nurse should monitor a client who is postpartum from a forceps delivery for which of the following complications?
- A. Placental abruption.
- B. Seizure.
- C. Idiopathic thrombocytopenia.
- D. Infection.
Correct Answer: D
Rationale: Forceps delivery increases the risk of trauma and infection due to potential tissue damage.
The triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?
- A. Have any of your partners ever hurt you?'
- B. Do you ever have unprotected intercourse?'
- C. Have you ever had a baby?'
- D. Do you think you may be pregnant?'
Correct Answer: B
Rationale: Unprotected intercourse increases the risk of sexually transmitted infections (STIs), which could explain the hard lump.
A baby is exhibiting signs of neonatal abstinence syndrome. Which action would be appropriate for the nursery nurse to make?
- A. Cover the baby with at least two blankets.
- B. Stimulate the baby with rattles.
- C. Play soft classical music in the nursery.
- D. Attach a mobile to the crib.
Correct Answer: A
Rationale: Neonatal abstinence syndrome babies are sensitive to stimuli, so minimizing environmental stimulation, such as by swaddling, is important.
Which of the patient health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy?
- A. Sexual intercourse two or three times weekly
- B. Moderate exercise for 30 minutes daily
- C. Working 40 hours a week as a secretary in a travel agency
- D. Relaxing in a hot tub for 30 minutes a day, several days a week
Correct Answer: D
Rationale: The correct answer is D because relaxing in a hot tub for 30 minutes a day, several days a week can increase the body temperature, which is harmful during the first trimester and can lead to birth defects. Choice A is not a risk factor as it promotes a healthy sexual relationship. Choice B is beneficial as moderate exercise is recommended during pregnancy. Choice C is not necessarily a risk factor unless it involves exposure to harmful substances or excessive stress.