Nokea
A labor and delivery nurse is assessing a newborn baby boy. Which finding would indicate possible microcephaly?
- A. depressed fontanelles during feeding
- B. hypoactivity
- C. head circumference in lowest tenth percentile
- D. absent fontanelles
Correct Answer: C
Rationale: Microcephaly is defined by a head circumference significantly below normal (e.g., lowest 10th percentile), indicating potential brain development issues.
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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
All of the following are parts of the middle ear EXCEPT the
- A. pinna.
- B. incus.
- C. stapes.
- D. malleus.
Correct Answer: A
Rationale: The middle ear includes the incus, stapes, and malleus (ossicles). The pinna is part of the outer ear.
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
- A. Inspection, auscultation, palpation
- B. Auscultation, palpation, inspection
- C. Palpation, inspection, auscultation
- D. Inspection, palpation, auscultation
Correct Answer: A
Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.
Following a disaster with multiple victims and danger to those present, which group should have priority for protection from injury?
- A. The clients/victims.
- B. The firefighters and police officers.
- C. The bystanders and news reporters.
- D. The healthcare providers.
Correct Answer: B
Rationale: Firefighters and police officers (B) have priority for protection as they are essential for managing the disaster and ensuring safety for others. Victims (A), bystanders (C), and healthcare providers (D) follow in priority.
The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.
Correct Answer: 31
Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.