A healthcare professional is reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?
- A. The cervix is pink.
- B. The cervix is midline.
- C. The cervix is about 1 inch in diameter.
- D. Clear secretions with a foul odor are noted on the cervix.
Correct Answer: D
Rationale: The correct answer is 'Clear secretions with a foul odor are noted on the cervix.' Normally, the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may vary. However, they should always be odorless and nonirritating. Secretions with a foul odor are indicative of an infection, making this finding abnormal. Choices A, B, and C describe normal cervix characteristics, so they do not indicate an abnormality in this scenario.
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Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes is a significant factor that can impact the body image of an infant newly diagnosed with Hemophilia. Infants are highly sensitive to the reactions of their caregivers, and a new diagnosis like Hemophilia can introduce stress and uncertainties into the family dynamics. This can affect the infant's sense of security, trust development, and how they perceive themselves. Immobility, while a potential long-term effect of Hemophilia, is not the immediate impact on body image for a newly diagnosed infant. Altered growth and development would take time to manifest and would not be an immediate concern after a recent diagnosis. Hemarthrosis, although a characteristic symptom of Hemophilia, is a physical manifestation rather than a direct influence on body image perception in a newly diagnosed infant.
While assisting with data collection regarding the neurological system, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?
- A. Vagus
- B. Facial
- C. Abducens
- D. Oculomotor
Correct Answer: B
Rationale: The correct answer is B: Facial. Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client performs various facial movements, including puffing out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together for different functions. The abducens, oculomotor, and trochlear nerves are assessed together for eye movements and pupil reactions, not cheek puffing.
In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
- A. measles, polio, pertussis, hepatitis B
- B. diphtheria, pertussis, polio, tetanus
- C. rubella, polio, pertussis, hepatitis A
- D. measles, mumps, rubella, polio
Correct Answer: B
Rationale: By 12 months of age, children should have received vaccines for diphtheria, pertussis, polio, and tetanus (DTaP and IPV). The correct answer is B as it includes these vaccines that are typically administered in the first year of life. Measles, mumps, and rubella (MMR) vaccination usually begins at 12 months of age but is not expected to be completed by this time. Choices A and C are incorrect as they include diseases that are not part of the routine immunization schedule for a 12-month-old child.
Regarding maternal and infant mortality and morbidity, a concern is that:
- A. a segment of the population is not receiving prenatal care.
- B. families may not prioritize quality health care.
- C. there might be an increase in the shortage of personnel in the maternity field.
- D. maternal-child health workers may lack adequate preparation.
Correct Answer: A
Rationale: The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.
While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?
- A. Trochlear nerve
- B. Abducens nerve
- C. Trigeminal nerve
- D. Oculomotor nerve
Correct Answer: C
Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.
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